Provider Demographics
NPI:1548966633
Name:GRAHAM, KYLEE SAMANTHA (PA-C)
Entity type:Individual
Prefix:
First Name:KYLEE
Middle Name:SAMANTHA
Last Name:GRAHAM
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5 PIERCE CIR
Mailing Address - Street 2:
Mailing Address - City:PAXTON
Mailing Address - State:MA
Mailing Address - Zip Code:01612-1078
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3100 E FLETCHER AVE
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33613-4613
Practice Address - Country:US
Practice Address - Phone:407-303-7283
Practice Address - Fax:407-303-0473
Is Sole Proprietor?:No
Enumeration Date:2023-02-01
Last Update Date:2024-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363AM0700X
FLPA9118359363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical