Healthcare Provider Details

I. General information

NPI: 1508758699
Provider Name (Legal Business Name): GRAHAM WILLIAM PARKS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/15/2025
Last Update Date: 09/12/2026
Certification Date: 09/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24900 SE STARK ST STE 205
GRESHAM OR
97030-3382
US

IV. Provider business mailing address

3720 S BOND AVE UNIT 1210
PORTLAND OR
97239-4574
US

V. Phone/Fax

Practice location:
  • Phone: 503-665-1010
  • Fax:
Mailing address:
  • Phone: 859-213-6713
  • Fax:

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: