Provider Demographics
NPI:1134852791
Name:GRAHAM, MARIAN THERESA
Entity type:Individual
Prefix:
First Name:MARIAN
Middle Name:THERESA
Last Name:GRAHAM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:190 HATCHER LN STE B
Mailing Address - Street 2:
Mailing Address - City:CLARKSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37043-5989
Mailing Address - Country:US
Mailing Address - Phone:931-221-0902
Mailing Address - Fax:931-221-0602
Practice Address - Street 1:190 HATCHER LN STE B
Practice Address - Street 2:
Practice Address - City:CLARKSVILLE
Practice Address - State:TN
Practice Address - Zip Code:37043-5989
Practice Address - Country:US
Practice Address - Phone:931-221-0902
Practice Address - Fax:931-221-0602
Is Sole Proprietor?:No
Enumeration Date:2022-07-01
Last Update Date:2025-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA18404363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant