Provider Demographics
NPI:1699770842
Name:LARAISO, RALPH G (DO)
Entity type:Individual
Prefix:DR
First Name:RALPH
Middle Name:G
Last Name:LARAISO
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:723 MEMORIAL ST
Mailing Address - Street 2:
Mailing Address - City:PROSSER
Mailing Address - State:WA
Mailing Address - Zip Code:99350-1524
Mailing Address - Country:US
Mailing Address - Phone:509-786-1576
Mailing Address - Fax:509-788-6013
Practice Address - Street 1:336 CHARDONNAY AVE STE A
Practice Address - Street 2:
Practice Address - City:PROSSER
Practice Address - State:WA
Practice Address - Zip Code:99350-9515
Practice Address - Country:US
Practice Address - Phone:509-786-1576
Practice Address - Fax:509-788-6013
Is Sole Proprietor?:No
Enumeration Date:2005-06-15
Last Update Date:2024-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34.11223208100000X
NY235585208100000X
MO2011032951208100000X
WAOP60722041208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02697423Medicaid
NYE85834Medicare UPIN
NYIA0981Medicare PIN