Provider Demographics
NPI:1992129704
Name:GRAHAM, GARY LEE (NP)
Entity type:Individual
Prefix:
First Name:GARY
Middle Name:LEE
Last Name:GRAHAM
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:34290 FORD RD
Mailing Address - Street 2:
Mailing Address - City:WESTLAND
Mailing Address - State:MI
Mailing Address - Zip Code:48185-3051
Mailing Address - Country:US
Mailing Address - Phone:734-324-8326
Mailing Address - Fax:
Practice Address - Street 1:34290 FORD RD
Practice Address - Street 2:
Practice Address - City:WESTLAND
Practice Address - State:MI
Practice Address - Zip Code:48185-3051
Practice Address - Country:US
Practice Address - Phone:734-324-8326
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-02-13
Last Update Date:2024-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704197715363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health