Provider Demographics
NPI:1457966913
Name:GRAHAM, ERIC KEVIN (PA-C)
Entity type:Individual
Prefix:
First Name:ERIC
Middle Name:KEVIN
Last Name:GRAHAM
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8173 MIDTOWN BLVD APT 3312
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75231-4493
Mailing Address - Country:US
Mailing Address - Phone:972-322-1757
Mailing Address - Fax:
Practice Address - Street 1:3801 WILLIAM D TATE AVE # 800A
Practice Address - Street 2:
Practice Address - City:GRAPEVINE
Practice Address - State:TX
Practice Address - Zip Code:76051-8755
Practice Address - Country:US
Practice Address - Phone:817-488-8998
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-11
Last Update Date:2020-10-05
Deactivation Date:
Deactivation Code:
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Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXPA13678OtherTEXAS PHYSICIAN ASSISTANT BOARD
1172707OtherNATIONAL COMMISSION ON CERTIFICATION OF PHYSICIAN ASSISTANTS