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General NPI Number Information
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NPI Number | 1730844838
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Entity Type | Individual
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Provider Name | GRAHAM MICHAEL GENTRY FNP
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Gender | Male
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Dates
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Enumeration Date | 11/03/2021
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Last Update Date | 11/04/2025
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Provider Practice Location Address
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Address Line | 1755 SW BAKER ST
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City | MCMINNVILLE
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State | OR
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Zip | 97128-9112
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Country | US
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Telephone | 971-900-4522
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Fax | 971-900-4503
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Provider Business Mailing Address
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Address Line | 600 JEFFERSON ST STE 600
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City | LAFAYETTE
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State | LA
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Zip | 70501-6987
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Country | US
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Telephone | 458-201-5074
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Fax | 337-465-4604
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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 | AP61241707
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License Number State | WA
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Taxonomy #2
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Taxonomy Code | 207R00000X
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Taxonomy Name | Internal Medicine Physician
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License Number | 202109761NP
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License Number State | OR
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Taxonomy #3
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Taxonomy Code | 363LF0000X
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Taxonomy Name | Family Nurse Practitioner
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License Number | 202109761NP-PP
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License Number State | OR
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