Provider Demographics
NPI:1992306781
Name:RAYBURN, ERIC
Entity type:Individual
Prefix:
First Name:ERIC
Middle Name:
Last Name:RAYBURN
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3400 SPRUCE STREET
Mailing Address - Street 2:DULLES BLDG., SUITE 680
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19104
Mailing Address - Country:US
Mailing Address - Phone:215-349-8310
Mailing Address - Fax:215-893-7270
Practice Address - Street 1:3400 SPRUCE STREET
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19104-4206
Practice Address - Country:US
Practice Address - Phone:215-349-8310
Practice Address - Fax:215-893-7270
Is Sole Proprietor?:No
Enumeration Date:2020-11-06
Last Update Date:2025-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARN673303367500000X
NJ26NJ01074400367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered