Provider Demographics
NPI:1124473889
Name:RAIZER, TAL (NP)
Entity type:Individual
Prefix:MS
First Name:TAL
Middle Name:
Last Name:RAIZER
Suffix:
Gender:
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1310 SW 160TH AVE
Mailing Address - Street 2:
Mailing Address - City:SUNRISE
Mailing Address - State:FL
Mailing Address - Zip Code:33326-1907
Mailing Address - Country:US
Mailing Address - Phone:954-719-5634
Mailing Address - Fax:954-231-5952
Practice Address - Street 1:1310 SW 160TH AVE
Practice Address - Street 2:
Practice Address - City:SUNRISE
Practice Address - State:FL
Practice Address - Zip Code:33326-1907
Practice Address - Country:US
Practice Address - Phone:954-719-5634
Practice Address - Fax:954-231-5952
Is Sole Proprietor?:No
Enumeration Date:2016-05-02
Last Update Date:2025-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024173505363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAC05501OtherMEDICARE GROUP