Provider Demographics
NPI:1710619085
Name:GRAFF, ALYSSA EDEN
Entity type:Individual
Prefix:
First Name:ALYSSA
Middle Name:EDEN
Last Name:GRAFF
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:ALYSSA
Other - Middle Name:EDEN
Other - Last Name:WATSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:4357 W WEDGE DR
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72704-7517
Mailing Address - Country:US
Mailing Address - Phone:918-833-4555
Mailing Address - Fax:
Practice Address - Street 1:4301 GREATHOUSE SPRINGS RD
Practice Address - Street 2:
Practice Address - City:JOHNSON
Practice Address - State:AR
Practice Address - Zip Code:72741
Practice Address - Country:US
Practice Address - Phone:956-665-7049
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-27
Last Update Date:2025-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
ARPA-1356207VG0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program