Healthcare Provider Details

I. General information

NPI: 1720331143
Provider Name (Legal Business Name): DAVIS MICHAEL GRAHAM PH.D., RN, CNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/23/2012
Last Update Date: 10/24/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2001 BLOOMINGTON AVE
MINNEAPOLIS MN
55404-3074
US

IV. Provider business mailing address

2001 BLOOMINGTON AVE
MINNEAPOLIS MN
55404-3074
US

V. Phone/Fax

Practice location:
  • Phone: 612-638-0700
  • Fax: 612-638-0685
Mailing address:
  • Phone: 612-638-0700
  • Fax: 612-638-0685

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberR 189172-6
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: