Healthcare Provider Details

I. General information

NPI: 1740830637
Provider Name (Legal Business Name): DANIEL GRAHAM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/13/2019
Last Update Date: 10/23/2024
Certification Date: 10/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2923 E 29TH AVE
SPOKANE WA
99223-4811
US

IV. Provider business mailing address

PO BOX 2928
PORTLAND OR
97208-2928
US

V. Phone/Fax

Practice location:
  • Phone: 888-227-3312
  • Fax: 509-227-7070
Mailing address:
  • Phone: 425-207-5155
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA61595338
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: