Healthcare Provider Details

I. General information

NPI: 1730844838
Provider Name (Legal Business Name): GRAHAM MICHAEL GENTRY FNP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/03/2021
Last Update Date: 11/04/2025
Certification Date: 11/04/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1755 SW BAKER ST
MCMINNVILLE OR
97128-9112
US

IV. Provider business mailing address

600 JEFFERSON ST STE 600
LAFAYETTE LA
70501-6987
US

V. Phone/Fax

Practice location:
  • Phone: 971-900-4522
  • Fax: 971-900-4503
Mailing address:
  • Phone: 458-201-5074
  • Fax: 337-465-4604

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAP61241707
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number202109761NP
License Number StateOR
# 3
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number202109761NP-PP
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: