Provider Demographics
NPI:1922289107
Name:GRAHAM, PHILIP DOUGLAS (PA)
Entity Type:Individual
Prefix:
First Name:PHILIP
Middle Name:DOUGLAS
Last Name:GRAHAM
Suffix:
Gender:M
Credentials:PA
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 505
Mailing Address - Street 2:
Mailing Address - City:NORTH CHILLI
Mailing Address - State:NY
Mailing Address - Zip Code:14514-0505
Mailing Address - Country:US
Mailing Address - Phone:585-594-5995
Mailing Address - Fax:585-594-5425
Practice Address - Street 1:4201 BUFFALO ROAD
Practice Address - Street 2:SUITE 1
Practice Address - City:NORTH CHILI
Practice Address - State:NY
Practice Address - Zip Code:14514-1256
Practice Address - Country:US
Practice Address - Phone:585-594-5995
Practice Address - Fax:585-594-5995
Is Sole Proprietor?:No
Enumeration Date:2007-11-16
Last Update Date:2023-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY012180363AS0400X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02942809Medicaid
NYPA2239Medicare PIN
NYPA2240Medicare PIN