MEDICARE: CHRISTINA ELIZABETH GRAHAM

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	174400000X	Specialist	D6333580	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	03-089121	OTHER	CA	CASR

General Provider Information

NPI Number	:	1982859948
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CHRISTINA ELIZABETH GRAHAM

Provider Business Mailing Address
First Line	:	2811 COLD SPRINGS RD APT 47
Second Line	:
City	:	PLACERVILLE
State	:	CA
Zip	:	95667-4018
Country	:	US
Telephone Number	:	530-748-9358
Fax Number	:

Provider Business Practice Location Address
First Line	:	2811 COLD SPRINGS RD APT 47
Second Line	:
City	:	PLACERVILLE
State	:	CA
Zip	:	95667-4018
Country	:	US
Telephone Number	:	530-748-9358
Fax Number	:

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

Provider Enumeration Date	:	11/18/2008
Last Update Date	:	11/18/2008

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