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General NPI Number Information
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NPI Number | 1366875775
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Entity Type | Individual
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Provider Name | AUSTIN THOMAS GRAHAM OPA-C
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Gender | Male
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Dates
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Enumeration Date | 08/21/2013
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Last Update Date | 08/21/2013
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Provider Practice Location Address
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Address Line | 1103 WILLIAMS DR STE 1
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City | GEORGETOWN
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State | TX
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Zip | 78628-4109
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Country | US
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Telephone | 512-943-4506
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Fax | 512-943-4515
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Provider Business Mailing Address
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Address Line | 1103 WILLIAMS DRIVE, BLD4, STE1
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City | GEORGETOWN
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State | TX
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Zip | 78628
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Country | US
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Telephone | 512-943-4506
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Fax | 512-943-4515
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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 | 171W00000X
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Taxonomy Name | Contractor
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License Number | 46-3410679
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License Number State | TX
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