Provider Demographics
NPI:1194939199
Name:GRAHAM, MARISA ROSE (PA-C)
Entity type:Individual
Prefix:
First Name:MARISA
Middle Name:ROSE
Last Name:GRAHAM
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:743 FOLLY RD
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29412-3432
Mailing Address - Country:US
Mailing Address - Phone:828-762-2360
Mailing Address - Fax:828-762-2340
Practice Address - Street 1:1818 HENDERSON ST
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29201-2619
Practice Address - Country:US
Practice Address - Phone:803-758-2602
Practice Address - Fax:803-253-8896
Is Sole Proprietor?:No
Enumeration Date:2007-05-09
Last Update Date:2024-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-01328363A00000X
SC1154363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant