MEDICARE: DAVID GRAHAM RN, MSN, NP-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LG0600X	Gerontology Nurse Practitioner	1-129274	AL
2	363LG0600X	Gerontology Nurse Practitioner	APRN11001771	FL
3	363L00000X	Nurse Practitioner	1-129274	AL
4	163W00000X	Registered Nurse	T20071316	MD

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1053506899
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DAVID GRAHAM RN, MSN, NP-C

Provider Business Mailing Address
First Line	:	PO BOX 240132
Second Line	:
City	:	MONTGOMERY
State	:	AL
Zip	:	36124-0132
Country	:	US
Telephone Number	:	443-902-8816
Fax Number	:	334-323-7148

Provider Business Practice Location Address
First Line	:	5911 MONTICELLO DR
Second Line	:
City	:	MONTGOMERY
State	:	AL
Zip	:	36117-1940
Country	:	US
Telephone Number	:	443-902-8816
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/13/2007
Last Update Date	:	07/08/2024

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