Healthcare Provider Details

I. General information

NPI: 1326736422
Provider Name (Legal Business Name): GRAHAM TYLER VIRTUE PA-S
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/26/2023
Last Update Date: 10/09/2024
Certification Date: 10/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10150 NIAGARA LN N # 210
MAPLE GROVE MN
55369-7588
US

IV. Provider business mailing address

PO BOX 14909
MINNEAPOLIS MN
55414-0909
US

V. Phone/Fax

Practice location:
  • Phone: 612-871-1145
  • Fax: 612-870-5491
Mailing address:
  • Phone: 612-871-1145
  • Fax: 612-870-5491

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: