Provider Demographics
NPI:1366875775
Name:GRAHAM, AUSTIN THOMAS (OPA-C)
Entity type:Individual
Prefix:MR
First Name:AUSTIN
Middle Name:THOMAS
Last Name:GRAHAM
Suffix:
Gender:M
Credentials:OPA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1103 WILLIAMS DRIVE, BLD4, STE1
Mailing Address - Street 2:
Mailing Address - City:GEORGETOWN
Mailing Address - State:TX
Mailing Address - Zip Code:78628
Mailing Address - Country:US
Mailing Address - Phone:512-943-4506
Mailing Address - Fax:512-943-4515
Practice Address - Street 1:1103 WILLIAMS DR STE 1
Practice Address - Street 2:
Practice Address - City:GEORGETOWN
Practice Address - State:TX
Practice Address - Zip Code:78628-4109
Practice Address - Country:US
Practice Address - Phone:512-943-4506
Practice Address - Fax:512-943-4515
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-21
Last Update Date:2013-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX46-3410679171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor