MEDICARE: KENNETH DANIEL GRAHAM PHYSICIAN ASSISTANT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363AM0700X	Medical Physician Assistant	9114062	FL
2	363A00000X	Physician Assistant	0010-07556	NC

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1164941977
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KENNETH DANIEL GRAHAM PHYSICIAN ASSISTANT

Provider Business Mailing Address
First Line	:	7555 LOON AVE
Second Line	:
City	:	WINTER GARDEN
State	:	FL
Zip	:	34787-5493
Country	:	US
Telephone Number	:	678-764-4234
Fax Number	:

Provider Business Practice Location Address
First Line	:	5716 FAYETTEVILLE RD
Second Line	:
City	:	DURHAM
State	:	NC
Zip	:	27713-9661
Country	:	US
Telephone Number	:	919-572-1868
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/12/2017
Last Update Date	:	02/22/2024

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