MEDICARE: LISETH GRAHAM P.A.

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	246ZC0007X	Surgical Assistant	25-499	FL
2	363AS0400X	Surgical Physician Assistant	3180-P.A.	PR
3	363A00000X	Physician Assistant	3180-P.A.	PR

General Provider Information

NPI Number	:	1285566703
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LISETH GRAHAM P.A.

Provider Business Mailing Address
First Line	:	851 BREVARD CT
Second Line	:
City	:	ORLANDO
State	:	FL
Zip	:	32822-8118
Country	:	US
Telephone Number	:	646-920-8937
Fax Number	:

Provider Business Practice Location Address
First Line	:	851 BREVARD CT
Second Line	:
City	:	ORLANDO
State	:	FL
Zip	:	32822-8118
Country	:	US
Telephone Number	:	646-920-8937
Fax Number	:

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

Provider Enumeration Date	:	06/01/2026
Last Update Date	:	06/01/2026

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