Provider Demographics
NPI:1053063347
Name:THEODORA C RAFT NP, PC
Entity Type:Organization
Organization Name:THEODORA C RAFT NP, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NP
Authorized Official - Prefix:
Authorized Official - First Name:THEODORA
Authorized Official - Middle Name:C
Authorized Official - Last Name:RAFT
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:631-617-2416
Mailing Address - Street 1:7 CREST CT
Mailing Address - Street 2:
Mailing Address - City:MIDDLE ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:11953-2135
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:290 MAIN ST
Practice Address - Street 2:
Practice Address - City:EAST SETAUKET
Practice Address - State:NY
Practice Address - Zip Code:11733-2871
Practice Address - Country:US
Practice Address - Phone:631-751-0441
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-01-19
Last Update Date:2022-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty