Provider Demographics
NPI:1043706856
Name:GRAHAM, STEPHANIE (PAC)
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:
Last Name:GRAHAM
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6774 KLINE ST
Mailing Address - Street 2:
Mailing Address - City:ARVADA
Mailing Address - State:CO
Mailing Address - Zip Code:80004-1548
Mailing Address - Country:US
Mailing Address - Phone:630-440-3899
Mailing Address - Fax:
Practice Address - Street 1:777 BANNOCK ST
Practice Address - Street 2:
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80204-4597
Practice Address - Country:US
Practice Address - Phone:303-602-3899
Practice Address - Fax:303-602-3902
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-04
Last Update Date:2024-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO363AM0700X
COPA.0005464363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedicalGroup - Single Specialty