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General NPI Number Information
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NPI Number | 1417218157
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Entity Type | Individual
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Provider Name | CHARLES M GRAHAM JR. SA
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Gender | Male
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Dates
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Enumeration Date | 05/30/2012
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Last Update Date | 05/30/2012
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Provider Practice Location Address
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Address Line | 1069 W BROAD ST SUITE 908
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City | FALLS CHURCH
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State | VA
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Zip | 22046-4610
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Country | US
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Telephone | 540-239-4852
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Fax |
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Provider Business Mailing Address
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Address Line | 5119 PRESTWICK DR
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City | FAIRFAX
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State | VA
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Zip | 22030-4537
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Country | US
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Telephone | 540-239-4852
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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 | 246ZC0007X
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Taxonomy Name | Surgical Assistant
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License Number |
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License Number State |
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