Provider Demographics
NPI:1629531306
Name:GRAHAM, TATIANA (PA-C)
Entity Type:Individual
Prefix:
First Name:TATIANA
Middle Name:
Last Name:GRAHAM
Suffix:
Gender:F
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:PO BOX 551308
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32255-1308
Mailing Address - Country:US
Mailing Address - Phone:904-493-3333
Mailing Address - Fax:904-493-2222
Practice Address - Street 1:7011 A C SKINNER PKWY STE 160
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32256-6953
Practice Address - Country:US
Practice Address - Phone:904-493-3333
Practice Address - Fax:904-493-2222
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-10
Last Update Date:2022-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9113745363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL113130200Medicaid