Basic Information
| Provider Information | |||||||||
| NPI: | 1770527285 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GRABER | ||||||||
| FirstName: | JONATHAN | ||||||||
| MiddleName: | C | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 330 LAKEVIEW DR | ||||||||
| Address2: | |||||||||
| City: | GOSHEN | ||||||||
| State: | IN | ||||||||
| PostalCode: | 465289365 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5745331234 | ||||||||
| FaxNumber: | 5745372652 | ||||||||
| Practice Location | |||||||||
| Address1: | 330 LAKEVIEW DR | ||||||||
| Address2: | |||||||||
| City: | GOSHEN | ||||||||
| State: | IN | ||||||||
| PostalCode: | 465289365 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5745331234 | ||||||||
| FaxNumber: | 5745372652 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/15/2006 | ||||||||
| LastUpdateDate: | 11/07/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LA2200X | 71000256A | IN | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health | 163WP0808X | 28113375A | IN | N | Nursing Service Providers | Registered Nurse | Psych/Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 200125900 | 05 | IN | MEDICAID | 000000531843 | 01 | ANTHEM PIN | OTHER | P00090584 | 01 | IN | RAILROAD MEDICARE PIN | OTHER |