Provider Demographics
NPI:1316209703
Name:GRAHAM, KRISTIN ELIZABETH (PA-C)
Entity type:Individual
Prefix:MRS
First Name:KRISTIN
Middle Name:ELIZABETH
Last Name:GRAHAM
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MISS
Other - First Name:KRISTIN
Other - Middle Name:ELIZABETH
Other - Last Name:MANEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:1351 ROUTE 55
Mailing Address - Street 2:SUITE 200
Mailing Address - City:LAGRANGEVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:12540-5108
Mailing Address - Country:US
Mailing Address - Phone:845-475-9661
Mailing Address - Fax:845-475-9938
Practice Address - Street 1:45 READE PL
Practice Address - Street 2:
Practice Address - City:POUGHKEEPSIE
Practice Address - State:NY
Practice Address - Zip Code:12601-3947
Practice Address - Country:US
Practice Address - Phone:845-437-3152
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-06-12
Last Update Date:2022-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY015670363AS0400X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03501186Medicaid
NYA400076271Medicare PIN