Healthcare Provider Details

I. General information

NPI: 1730317728
Provider Name (Legal Business Name): NICHOLAS JAMES GRAHAM IDMT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/29/2009
Last Update Date: 06/29/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2504 S.CHICAGO ST
FAIRCHILD AFB WA
99011
US

IV. Provider business mailing address

4320 W.DESKA DR APT 601
SPOKANE WA
99224
US

V. Phone/Fax

Practice location:
  • Phone: 509-657-5414
  • Fax:
Mailing address:
  • Phone: 360-701-1192
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1710I1003X
TaxonomyIndependent Duty Medical Technicians
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: