Healthcare Provider Details

I. General information

NPI: 1902701972
Provider Name (Legal Business Name): TREVIN SHANE GRAHAM
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/10/2026
Last Update Date: 10/10/2026
Certification Date: 10/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3384 S 2620 E
SAINT GEORGE UT
84790-6667
US

IV. Provider business mailing address

3384 S 2620 E
SAINT GEORGE UT
84790-6667
US

V. Phone/Fax

Practice location:
  • Phone: 801-718-4814
  • Fax:
Mailing address:
  • Phone: 801-718-4814
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number5044246-4405
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: