Healthcare Provider Details

I. General information

NPI: 1811947344
Provider Name (Legal Business Name): ADAM W GRAHAM P.A.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/12/2006
Last Update Date: 08/19/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12499 CLAIMSTAKE CT
LOLO MT
59847-9435
US

IV. Provider business mailing address

12499 CLAIMSTAKE CT
LOLO MT
59847-9435
US

V. Phone/Fax

Practice location:
  • Phone: 406-493-8269
  • Fax:
Mailing address:
  • Phone: 406-493-8269
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number5703835-1206
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number5703835-1206
License Number StateUT
# 3
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberMT 503
License Number StateMT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: