Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 207ND0101X | MOHS-Micrographic Surgeon | 262904 | MA |
Y | 207ND0101X | MOHS-Micrographic Surgeon | 282257-1 | NY |
N | 207R00000X | Internist | MT199988 | PA |
N | 111NI0900X | Internist | MT199988 | PA |
NPI | 1205121324 |
---|---|
Provider Name | Brian Raphael |
First Address | East Syracuse, NY 13057-3084 |
Second Address | East Syracuse, NY 13057-3084 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 16/06/2011 |
Last Update Date | 10/11/2016 |