Healthcare Provider Details

I. General information

NPI: 1326519067
Provider Name (Legal Business Name): PAUL GRAHAM JR.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/06/2018
Last Update Date: 12/06/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25 W CRYSTAL LAKE ST
ORLANDO FL
32806-4475
US

IV. Provider business mailing address

4501 VINELAND RD STE 103
ORLANDO FL
32811-7375
US

V. Phone/Fax

Practice location:
  • Phone: 497-254-2558
  • Fax:
Mailing address:
  • Phone: 407-792-0031
  • Fax: 407-241-4992

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberPTA28830
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: