Individual
MR. MICHAEL CLYDE GRAHAM
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
P.A.
Contact information
Practice address
225 6TH ST, POTLATCH, ID 83855-5002
(208) 883-2220
Mailing address
225 6TH ST, POTLATCH, ID 83855-5002
(208) 883-2220
Taxonomy
Speciality
Code
Description
License number
State
363A00000X
Physician Assistant
Primary
PA594
ID
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
807364300
—
ID
Enumeration date
11/22/2006
Last updated
06/20/2012
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