Provider Demographics
NPI:1285317735
Name:GRAHAM, JASON TYLER GORDON (NP)
Entity type:Individual
Prefix:
First Name:JASON
Middle Name:TYLER GORDON
Last Name:GRAHAM
Suffix:
Gender:
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:105 WALL ST
Mailing Address - Street 2:
Mailing Address - City:POTEAU
Mailing Address - State:OK
Mailing Address - Zip Code:74953-4433
Mailing Address - Country:US
Mailing Address - Phone:918-635-3566
Mailing Address - Fax:918-635-3568
Practice Address - Street 1:104 WALL ST
Practice Address - Street 2:
Practice Address - City:POTEAU
Practice Address - State:OK
Practice Address - Zip Code:74953-4405
Practice Address - Country:US
Practice Address - Phone:918-635-3508
Practice Address - Fax:918-635-3550
Is Sole Proprietor?:No
Enumeration Date:2023-08-10
Last Update Date:2025-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR222349363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily