Healthcare Provider Details

I. General information

NPI: 1184675043
Provider Name (Legal Business Name): JEAN M. GRAHAM PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MS. JEAN MARTIN

II. Dates (important events)

Enumeration Date: 05/15/2006
Last Update Date: 09/13/2022
Certification Date: 08/12/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

259 1ST ST
MINEOLA NY
11501-3957
US

IV. Provider business mailing address

700 HICKSVILLE RD SUITE 204
BETHPAGE NY
11714-3471
US

V. Phone/Fax

Practice location:
  • Phone: 516-663-2727
  • Fax: 516-663-8549
Mailing address:
  • Phone: 516-576-5812
  • Fax: 516-576-5801

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number003524
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: