Provider Demographics
NPI:1306508809
Name:RAPHAEL, TARAH
Entity type:Individual
Prefix:
First Name:TARAH
Middle Name:
Last Name:RAPHAEL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:354 OCEAN AVE APT 57
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11226-1341
Mailing Address - Country:US
Mailing Address - Phone:347-893-7564
Mailing Address - Fax:
Practice Address - Street 1:8000 UTOPIA PKWY
Practice Address - Street 2:
Practice Address - City:JAMAICA
Practice Address - State:NY
Practice Address - Zip Code:11439-3621
Practice Address - Country:US
Practice Address - Phone:718-215-7340
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-12
Last Update Date:2021-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant