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General NPI Number Information
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NPI Number | 1356401574
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Entity Type | Individual
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Provider Name | GREGG TRAVIS GRAHAM FNP
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Gender | Male
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Dates
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Enumeration Date | 12/11/2006
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Last Update Date | 06/04/2019
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Provider Practice Location Address
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Address Line | 354 COPPERFIELD BLVD NE
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City | CONCORD
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State | NC
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Zip | 28025-2402
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Country | US
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Telephone | 704-786-5122
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Fax | 704-782-8279
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Provider Business Mailing Address
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Address Line | 4601 PARK RD STE 300
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City | CHARLOTTE
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State | NC
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Zip | 28209-2290
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Country | US
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Telephone | 704-323-2090
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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 | 363LF0000X
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Taxonomy Name | Family Nurse Practitioner
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License Number | 5011714
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License Number State | NC
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Taxonomy #2
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Taxonomy Code | 363L00000X
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Taxonomy Name | Nurse Practitioner
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License Number | ARNP9332853
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License Number State | FL
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