Provider Demographics
NPI:1124037049
Name:GIOVANNONE, RAFFAELE D (PA - C)
Entity Type:Individual
Prefix:
First Name:RAFFAELE
Middle Name:D
Last Name:GIOVANNONE
Suffix:
Gender:M
Credentials:PA - C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1209 HIGHWAY 35 N
Mailing Address - Street 2:SUITE A
Mailing Address - City:ROCKPORT
Mailing Address - State:TX
Mailing Address - Zip Code:78382-3117
Mailing Address - Country:US
Mailing Address - Phone:361-729-9811
Mailing Address - Fax:361-729-9819
Practice Address - Street 1:1209 HIGHWAY 35 N
Practice Address - Street 2:SUITE A
Practice Address - City:ROCKPORT
Practice Address - State:TX
Practice Address - Zip Code:78382-3117
Practice Address - Country:US
Practice Address - Phone:361-729-9811
Practice Address - Fax:361-729-9819
Is Sole Proprietor?:No
Enumeration Date:2006-08-07
Last Update Date:2017-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA02131363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0089JJOtherBLUE CROSS NUMBER
TX154482701Medicaid
TX0089JJOtherBLUE CROSS NUMBER
TX00155UMedicare ID - Type UnspecifiedMEDICARE NUMBER