Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207R00000X | Internist | 2016028963 | MO |
Y | 111NI0900X | Internist | 2016028963 | MO |
NPI | 1003041625 |
---|---|
Provider Name | Geoffrey Glen Graham |
First Address | Joplin, MO 64804-0319 |
Second Address | Joplin, MO 64804-0319 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 27/05/2009 |
Last Update Date | 10/03/2020 |