Healthcare Provider Details

I. General information

NPI: 1740234772
Provider Name (Legal Business Name): JOHN JOSEPH GRAYKOSKI PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/22/2006
Last Update Date: 10/11/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1222 E WOODLAND AVE
BARRON WI
54812-1765
US

IV. Provider business mailing address

PO BOX 1510
EAU CLAIRE WI
54702-1510
US

V. Phone/Fax

Practice location:
  • Phone: 715-537-3166
  • Fax:
Mailing address:
  • Phone: 715-838-5222
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number1944023
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code207PE0004X
TaxonomyEmergency Medical Services (Emergency Medicine) Physician
License Number1944023
License Number StateWI
# 3
Primary TaxonomyN
Taxonomy Code207PP0204X
TaxonomyPediatric Emergency Medicine (Emergency Medicine) Physician
License Number1944023
License Number StateWI
# 4
Primary TaxonomyN
Taxonomy Code207PT0002X
TaxonomyMedical Toxicology (Emergency Medicine) Physician
License Number1944023
License Number StateWI
# 5
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number1944
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: