Healthcare Provider Details

I. General information

NPI: 1649243494
Provider Name (Legal Business Name): MOIRA E GRAHAM PNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/10/2006
Last Update Date: 11/09/2023
Certification Date: 11/09/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1117 W DE LA ROSA ST
DEL RIO TX
78840
US

IV. Provider business mailing address

PO BOX 1470
EAGLE PASS TX
78853-1470
US

V. Phone/Fax

Practice location:
  • Phone: 830-768-4800
  • Fax: 830-768-4844
Mailing address:
  • Phone: 830-773-8917
  • Fax: 830-773-1892

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License NumberA109911
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number633353
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: