Healthcare Provider Details

I. General information

NPI: 1386739696
Provider Name (Legal Business Name): GRAHAM MICHAEL WILSON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/03/2006
Last Update Date: 12/17/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7151 CASCADE VALLEY CT STE 200
LAS VEGAS NV
89128-0498
US

IV. Provider business mailing address

7470 DEAN MARTIN DR STE 101
LAS VEGAS NV
89139-5944
US

V. Phone/Fax

Practice location:
  • Phone: 702-568-8450
  • Fax: 702-568-8451
Mailing address:
  • Phone: 702-568-8450
  • Fax: 702-568-8451

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number3724
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: