Provider Demographics
NPI:1619258068
Name:GRAHAM, MACKENZIE E T (PA-C, MPH)
Entity Type:Individual
Prefix:
First Name:MACKENZIE
Middle Name:E T
Last Name:GRAHAM
Suffix:
Gender:F
Credentials:PA-C, MPH
Other - Prefix:
Other - First Name:MACKENZIE
Other - Middle Name:E
Other - Last Name:TOMAZIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C, MPH
Mailing Address - Street 1:309 IVES LN
Mailing Address - Street 2:
Mailing Address - City:KETTERING
Mailing Address - State:OH
Mailing Address - Zip Code:45429-3006
Mailing Address - Country:US
Mailing Address - Phone:570-449-6447
Mailing Address - Fax:
Practice Address - Street 1:ONE WYOMING STREET
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45409
Practice Address - Country:US
Practice Address - Phone:937-208-2665
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-08-30
Last Update Date:2011-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH003317363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical