Provider Demographics
NPI:1992085310
Name:GRAHAM, ELIZABETH JEAN (APRN-C)
Entity type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:JEAN
Last Name:GRAHAM
Suffix:
Gender:F
Credentials:APRN-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:689 E 19TH AVE
Mailing Address - Street 2:
Mailing Address - City:EUGENE
Mailing Address - State:OR
Mailing Address - Zip Code:97401-4304
Mailing Address - Country:US
Mailing Address - Phone:541-868-1876
Mailing Address - Fax:541-868-0932
Practice Address - Street 1:3011 N MICHIGAN ST
Practice Address - Street 2:
Practice Address - City:PITTSBURG
Practice Address - State:KS
Practice Address - Zip Code:66762-2546
Practice Address - Country:US
Practice Address - Phone:620-231-1960
Practice Address - Fax:620-231-2808
Is Sole Proprietor?:No
Enumeration Date:2011-08-17
Last Update Date:2021-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR202006374NP-PP363LP2300X
KS5375433011363LF0000X
KS53-75433-011363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS068002207OtherMEDICARE PTAN
KS200875510CMedicaid