1528122546 NPI number — MS. MAI LINH T GRAHAM PA-C

Table of content: MS. MAI LINH T GRAHAM PA-C (NPI 1528122546)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1528122546 NPI number — MS. MAI LINH T GRAHAM PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GRAHAM
Provider First Name:
MAI LINH
Provider Middle Name:
T
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
PA-C
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1528122546
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/18/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 2616
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NEW SMYRNA BEACH
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32170-2616
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
386-427-0390
Provider Business Mailing Address Fax Number:
386-427-0394

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1722 STATE ROAD 44
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NEW SMYRNA BEACH
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32168-8339
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
386-427-0390
Provider Business Practice Location Address Fax Number:
386-427-0394
Provider Enumeration Date:
12/21/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363AS0400X , with the licence number:  PA757 , registered in the state of NV ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363AM0700X , with the licence number: PA9107182 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)