Healthcare Provider Details

I. General information

NPI: 1639830516
Provider Name (Legal Business Name): STEFIN ESTON GRAHAM CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/04/2022
Last Update Date: 01/04/2022
Certification Date: 01/04/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1214 COOLIDGE BLVD
LAFAYETTE LA
70503-2621
US

IV. Provider business mailing address

1972 CHERRYDALE AVE
BATON ROUGE LA
70808-2815
US

V. Phone/Fax

Practice location:
  • Phone: 337-289-7991
  • Fax:
Mailing address:
  • Phone: 225-571-8238
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number223708
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: