Provider Demographics
NPI:1326519067
Name:GRAHAM, PAUL JR
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:
Last Name:GRAHAM
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4501 VINELAND RD STE 103
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32811-7375
Mailing Address - Country:US
Mailing Address - Phone:407-792-0031
Mailing Address - Fax:407-241-4992
Practice Address - Street 1:25 W CRYSTAL LAKE ST
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32806-4475
Practice Address - Country:US
Practice Address - Phone:497-254-2558
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-12-06
Last Update Date:2018-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPTA28830225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant