Provider Demographics
NPI:1588342075
Name:RAPHAEL, CHARLEMAGNE (PHYSICIAN ASSISTANT)
Entity type:Individual
Prefix:
First Name:CHARLEMAGNE
Middle Name:
Last Name:RAPHAEL
Suffix:
Gender:M
Credentials:PHYSICIAN ASSISTANT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:220 SW 38TH AVE APT 104
Mailing Address - Street 2:
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33312-1871
Mailing Address - Country:US
Mailing Address - Phone:475-268-9328
Mailing Address - Fax:
Practice Address - Street 1:220 SW 38TH AVE APT 104
Practice Address - Street 2:
Practice Address - City:FORT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33312-1871
Practice Address - Country:US
Practice Address - Phone:475-268-9328
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-06
Last Update Date:2023-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR001358-PA207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine