Provider Demographics
NPI:1215247010
Name:RAYSOR, DEXTER LAMAR (SOIDC)
Entity type:Individual
Prefix:
First Name:DEXTER
Middle Name:LAMAR
Last Name:RAYSOR
Suffix:
Gender:M
Credentials:SOIDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:402 JACKSON ST
Mailing Address - Street 2:
Mailing Address - City:SUFFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23434
Mailing Address - Country:US
Mailing Address - Phone:757-539-3730
Mailing Address - Fax:
Practice Address - Street 1:402 JACKSON ST
Practice Address - Street 2:
Practice Address - City:SUFFOLK
Practice Address - State:VA
Practice Address - Zip Code:23434-5315
Practice Address - Country:US
Practice Address - Phone:757-539-3730
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-10-14
Last Update Date:2010-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA146L00000X
NC363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No146L00000XEmergency Medical Service ProvidersEmergency Medical Technician, Paramedic