Provider Demographics
NPI:1285414151
Name:GRAHAM, CHANDLER BRAY (PA)
Entity type:Individual
Prefix:
First Name:CHANDLER
Middle Name:BRAY
Last Name:GRAHAM
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:103 DARDEN DR
Mailing Address - Street 2:
Mailing Address - City:POQUOSON
Mailing Address - State:VA
Mailing Address - Zip Code:23662-1213
Mailing Address - Country:US
Mailing Address - Phone:757-951-3375
Mailing Address - Fax:
Practice Address - Street 1:401 E CHEVES ST STE 301
Practice Address - Street 2:
Practice Address - City:FLORENCE
Practice Address - State:SC
Practice Address - Zip Code:29506-2615
Practice Address - Country:US
Practice Address - Phone:843-777-7166
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-29
Last Update Date:2023-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCMPA.5064363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant