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General NPI Number Information
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NPI Number | 1962578153
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Entity Type | Individual
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Provider Name | HALCIAN L GRAHAM PAC
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Gender | Male
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Dates
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Enumeration Date | 11/28/2006
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Last Update Date | 02/15/2012
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Provider Practice Location Address
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Address Line | 2080 W EAU GALLIE BLVD SUITE A
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City | MELBOURNE
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State | FL
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Zip | 32935-3185
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Country | US
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Telephone | 321-254-6218
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Fax | 321-254-6230
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Provider Business Mailing Address
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Address Line | PO BOX 361907
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City | MELBOURNE
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State | FL
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Zip | 32936-1907
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Country | US
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Telephone | 321-254-6218
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Fax | 321-254-6230
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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 | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number | PA9103552
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License Number State | FL
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