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General NPI Number Information
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NPI Number | 1457529679
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Entity Type | Organization
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Legal Business Name | JENS F GRAVERSEN MD APM LLC
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Dates
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Enumeration Date | 02/11/2008
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Last Update Date | 06/04/2008
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Provider Practice Location Address
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Address Line | 15770 PAUL VEGA MD DR STE 200
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City | HAMMOND
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State | LA
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Zip | 70403-1475
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Country | US
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Telephone | 985-542-1226
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Fax | 985-542-2887
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Provider Business Mailing Address
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Address Line | 15770 PAUL VEGA MD DR STE 200
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City | HAMMOND
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State | LA
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Zip | 70403-1475
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Country | US
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Telephone | 985-542-1226
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Fax | 985-542-2887
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Authorized Official
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Title or Position | OFFICE MANAGER
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Name | MRS. TAMMY HARRIS
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Credential |
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Telephone | 985-542-1226
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208800000X
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Taxonomy Name | Urology Physician
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License Number | MD200326
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License Number State | LA
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