Basic Information
| Provider Information | |||||||||
| NPI: | 1033100631 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GRABHAM | ||||||||
| FirstName: | DANA | ||||||||
| MiddleName: | ELIZABETH | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PA | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | MISSELHORN | ||||||||
| OtherFirstName: | DANA | ||||||||
| OtherMiddleName: | ELIZABETH | ||||||||
| OtherNamePrefix: | MS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | PA | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 5434 E BARWICK DR | ||||||||
| Address2: | |||||||||
| City: | CAVE CREEK | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 853312404 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | |||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 3929 E BELL RD | ||||||||
| Address2: | |||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850322112 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6029235000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/02/2005 | ||||||||
| LastUpdateDate: | 11/03/2021 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 11/03/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 146D00000X | PA1012 | KY | N | Emergency Medical Service Providers | Personal Emergency Response Attendant | 363A00000X | 2746 | AZ | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 860373636 | 01 | AZ | HUMANA GROUP # | OTHER | 453051001 | 01 | AZ | GROUP HEALTH GRP # | OTHER | 3981220 | 01 | AZ | EVERCARE GROUP # | OTHER | 740771 | 05 | AZ | MEDICAID | AW1436 | 01 | AZ | HEALTHNET GRP # | OTHER |