Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 2080P0207X | Pediatric Hematology-Oncologist | 23389 | AZ |
NPI | 1164496923 |
---|---|
Provider Name | Michael Graham |
First Address | Mesa, AZ 85202-4768 |
Second Address | Mesa, AZ 85202-4768 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 16/02/2006 |
Last Update Date | 09/12/2010 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
D32577 | (02) | AZ |
Z138332 | ARIZONA MEDICARE FARGO PART B (01) | AZ |