Provider Demographics
NPI:1326013152
Name:NEISWONGER, RAYMOND ARTHUR (RN, ACNP, BC)
Entity type:Individual
Prefix:
First Name:RAYMOND
Middle Name:ARTHUR
Last Name:NEISWONGER
Suffix:
Gender:M
Credentials:RN, ACNP, BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6653 MAIN STREET
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:14221
Mailing Address - Country:US
Mailing Address - Phone:716-204-4500
Mailing Address - Fax:716-204-4501
Practice Address - Street 1:462 GRIDER STREET
Practice Address - Street 2:RM 741
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14215
Practice Address - Country:US
Practice Address - Phone:716-961-6995
Practice Address - Fax:716-898-5276
Is Sole Proprietor?:No
Enumeration Date:2006-02-23
Last Update Date:2009-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF430228-1363LC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LC0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerCritical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02663761Medicaid