Healthcare Provider Details

I. General information

NPI: 1356401574
Provider Name (Legal Business Name): GREGG TRAVIS GRAHAM FNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/11/2006
Last Update Date: 06/04/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

354 COPPERFIELD BLVD NE
CONCORD NC
28025-2402
US

IV. Provider business mailing address

4601 PARK RD STE 300
CHARLOTTE NC
28209-2290
US

V. Phone/Fax

Practice location:
  • Phone: 704-786-5122
  • Fax: 704-782-8279
Mailing address:
  • Phone: 704-323-2090
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number5011714
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberARNP9332853
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: