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General NPI Number Information
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NPI Number | 1033794839
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Entity Type | Individual
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Provider Name | WILLIAM GRAHAM ATC, LAT
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Gender | Male
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Dates
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Enumeration Date | 03/12/2021
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Last Update Date | 03/12/2021
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Provider Practice Location Address
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Address Line | 2168 FIELD HOUSE DR
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City | USAF ACADEMY
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State | CO
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Zip | 80840-9599
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Country | US
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Telephone | 719-333-0222
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Fax |
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Provider Business Mailing Address
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Address Line | 5210 SLICKROCK DR
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City | COLORADO SPRINGS
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State | CO
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Zip | 80923-7645
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Country | US
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Telephone | 720-984-5402
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2255A2300X
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Taxonomy Name | Athletic Trainer
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License Number | AT.0002083
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License Number State | CO
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