Healthcare Provider Details

I. General information

NPI: 1649295072
Provider Name (Legal Business Name): LISA D GRAHAM MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/13/2006
Last Update Date: 10/13/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

700 NE 87TH AVE
VANCOUVER WA
98664-1913
US

IV. Provider business mailing address

700 NE 87TH AVE
VANCOUVER WA
98664-1913
US

V. Phone/Fax

Practice location:
  • Phone: 360-882-2778
  • Fax: 360-604-1758
Mailing address:
  • Phone: 360-882-2778
  • Fax: 360-604-1758

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberMD00034426
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: