Provider Demographics
NPI:1730844838
Name:GENTRY, GRAHAM MICHAEL (FNP)
Entity type:Individual
Prefix:MR
First Name:GRAHAM
Middle Name:MICHAEL
Last Name:GENTRY
Suffix:
Gender:M
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 3777
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97208-3777
Mailing Address - Country:US
Mailing Address - Phone:503-666-5050
Mailing Address - Fax:
Practice Address - Street 1:9800 SE SUNNYSIDE RD
Practice Address - Street 2:
Practice Address - City:CLACKAMAS
Practice Address - State:OR
Practice Address - Zip Code:97015-9750
Practice Address - Country:US
Practice Address - Phone:503-652-2880
Practice Address - Fax:503-652-2880
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-03
Last Update Date:2024-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP61241707363LF0000X
OR202109761NP207R00000X
OR202109761NP-PP363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine