Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 207PE0004X | Emergency Medical Services | 200000436 | NC |
Y | 207PE0004X | Emergency Medical Services | R0007 | TX |
NPI | 1093756249 |
---|---|
Provider Name | Ted Graham |
First Address | College Station, TX 77845-7350 |
Second Address | Bryan, TX 77802-3014 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 09/06/2006 |
Last Update Date | 08/04/2020 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
891261N | (05) | NC |
G93592 | (02) | NC |