=====================================================
General NPI Number Information
=====================================================
NPI Number | 1558319558
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JOHN RICHARD GRAHAM CRNA
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/04/2006
-----------------------------------------------------
Last Update Date | 06/06/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 200 HAWTHORNE LANE
-----------------------------------------------------
City | CHARLOTTE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28204
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 704-384-4239
-----------------------------------------------------
Fax | 704-384-5636
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1525 W CYPRESS CREEK RD
-----------------------------------------------------
City | FORT LAUDERDALE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33309
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 954-939-5000
-----------------------------------------------------
Fax | 954-939-5000
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 367500000X
-----------------------------------------------------
Taxonomy Name | Certified Registered Nurse Anesthetist
-----------------------------------------------------
License Number | 054220
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 367500000X
-----------------------------------------------------
Taxonomy Name | Certified Registered Nurse Anesthetist
-----------------------------------------------------
License Number | APRN9196509
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------