Provider Demographics
NPI:1962578153
Name:GRAHAM, HALCIAN L (PAC)
Entity type:Individual
Prefix:
First Name:HALCIAN
Middle Name:L
Last Name:GRAHAM
Suffix:
Gender:M
Credentials:PAC
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 361907
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32936-1907
Mailing Address - Country:US
Mailing Address - Phone:321-254-6218
Mailing Address - Fax:321-254-6230
Practice Address - Street 1:2080 W EAU GALLIE BLVD
Practice Address - Street 2:SUITE A
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32935-3185
Practice Address - Country:US
Practice Address - Phone:321-254-6218
Practice Address - Fax:321-254-6230
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-28
Last Update Date:2012-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9103552363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLQ64737Medicare UPIN
FLU7040ZMedicare ID - Type UnspecifiedMEDICARE