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General NPI Number Information
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NPI Number | 1619258068
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Entity Type | Individual
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Provider Name | MACKENZIE E. T. GRAHAM PA-C, MPH
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Gender | Female
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Dates
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Enumeration Date | 08/30/2011
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Last Update Date | 08/30/2011
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Provider Practice Location Address
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Address Line | ONE WYOMING STREET
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City | DAYTON
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State | OH
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Zip | 45409
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Country | US
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Telephone | 937-208-2665
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Fax |
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Provider Business Mailing Address
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Address Line | 309 IVES LN
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City | KETTERING
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State | OH
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Zip | 45429-3006
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Country | US
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Telephone | 570-449-6447
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363AS0400X
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Taxonomy Name | Surgical Physician Assistant
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License Number | 003317
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License Number State | OH
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