Provider Demographics
NPI:1720331143
Name:GRAHAM, DAVIS MICHAEL (PHD, RN, CNP)
Entity type:Individual
Prefix:
First Name:DAVIS
Middle Name:MICHAEL
Last Name:GRAHAM
Suffix:
Gender:M
Credentials:PHD, RN, CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2001 BLOOMINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55404-3074
Mailing Address - Country:US
Mailing Address - Phone:612-638-0700
Mailing Address - Fax:612-638-0685
Practice Address - Street 1:2001 BLOOMINGTON AVE
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55404-3074
Practice Address - Country:US
Practice Address - Phone:612-638-0700
Practice Address - Fax:612-638-0685
Is Sole Proprietor?:No
Enumeration Date:2012-10-23
Last Update Date:2012-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR 189172-6363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health