Provider Demographics
NPI:1699781054
Name:GRAHAM, WAYNE R (DO)
Entity type:Individual
Prefix:DR
First Name:WAYNE
Middle Name:R
Last Name:GRAHAM
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 27128
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84127-0128
Mailing Address - Country:US
Mailing Address - Phone:435-657-4400
Mailing Address - Fax:435-657-4460
Practice Address - Street 1:1473 S HIGHWAY 40
Practice Address - Street 2:SUITE E
Practice Address - City:HEBER CITY
Practice Address - State:UT
Practice Address - Zip Code:84032-3522
Practice Address - Country:US
Practice Address - Phone:435-657-4400
Practice Address - Fax:435-657-4460
Is Sole Proprietor?:No
Enumeration Date:2006-07-31
Last Update Date:2014-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT59602551204207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT59602551204OtherSTATE LICENSE NO
UT000063272Medicare PIN