Provider Demographics
NPI:1184675043
Name:GRAHAM, JEAN M (PA)
Entity Type:Individual
Prefix:MS
First Name:JEAN
Middle Name:M
Last Name:GRAHAM
Suffix:
Gender:F
Credentials:PA
Other - Prefix:MS
Other - First Name:JEAN
Other - Middle Name:
Other - Last Name:MARTIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:700 HICKSVILLE RD
Mailing Address - Street 2:SUITE 204
Mailing Address - City:BETHPAGE
Mailing Address - State:NY
Mailing Address - Zip Code:11714-3471
Mailing Address - Country:US
Mailing Address - Phone:516-576-5812
Mailing Address - Fax:516-576-5801
Practice Address - Street 1:259 1ST ST
Practice Address - Street 2:
Practice Address - City:MINEOLA
Practice Address - State:NY
Practice Address - Zip Code:11501-3957
Practice Address - Country:US
Practice Address - Phone:516-663-2727
Practice Address - Fax:516-663-8549
Is Sole Proprietor?:No
Enumeration Date:2006-05-15
Last Update Date:2022-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY003524363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant