Provider Demographics
NPI:1467857532
Name:GRAHAM, KC (PA-C)
Entity Type:Individual
Prefix:
First Name:KC
Middle Name:
Last Name:GRAHAM
Suffix:
Gender:M
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 1:237 PROFESSIONAL WAY
Mailing Address - Street 2:
Mailing Address - City:SHELTON
Mailing Address - State:WA
Mailing Address - Zip Code:98584-4404
Mailing Address - Country:US
Mailing Address - Phone:360-426-2500
Mailing Address - Fax:
Practice Address - Street 1:237 PROFESSIONAL WAY
Practice Address - Street 2:
Practice Address - City:SHELTON
Practice Address - State:WA
Practice Address - Zip Code:98584-4404
Practice Address - Country:US
Practice Address - Phone:360-426-2500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-10-30
Last Update Date:2014-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA60509798363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant