Provider Demographics
NPI:1487759502
Name:GRAHAM, COURTNEY R (CRNA)
Entity type:Individual
Prefix:
First Name:COURTNEY
Middle Name:R
Last Name:GRAHAM
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6000 HOSPITAL DR.
Mailing Address - Street 2:P.O. BOX 551
Mailing Address - City:HANNIBAL
Mailing Address - State:MO
Mailing Address - Zip Code:63401-0551
Mailing Address - Country:US
Mailing Address - Phone:573-248-5621
Mailing Address - Fax:
Practice Address - Street 1:6000 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:HANNIBAL
Practice Address - State:MO
Practice Address - Zip Code:63401-6887
Practice Address - Country:US
Practice Address - Phone:573-248-5621
Practice Address - Fax:573-248-5264
Is Sole Proprietor?:No
Enumeration Date:2006-09-13
Last Update Date:2022-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARC01442207L00000X
IL209006952367500000X
MO146423367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO910840008Medicaid