Provider Demographics
NPI:1528122546
Name:GRAHAM, MAI LINH T (PA-C)
Entity type:Individual
Prefix:MS
First Name:MAI LINH
Middle Name:T
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:PO BOX 2616
Mailing Address - Street 2:
Mailing Address - City:NEW SMYRNA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32170-2616
Mailing Address - Country:US
Mailing Address - Phone:386-427-0390
Mailing Address - Fax:386-427-0394
Practice Address - Street 1:1722 STATE ROAD 44
Practice Address - Street 2:
Practice Address - City:NEW SMYRNA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32168-8339
Practice Address - Country:US
Practice Address - Phone:386-427-0390
Practice Address - Fax:386-427-0394
Is Sole Proprietor?:No
Enumeration Date:2006-12-21
Last Update Date:2015-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVPA757363AS0400X
FLPA9107182363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NVP77283Medicare UPIN