Provider Demographics
NPI:1144411596
Name:RAJNER, COLETTE
Entity Type:Individual
Prefix:
First Name:COLETTE
Middle Name:
Last Name:RAJNER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11050 MOUNT BELVEDERE BLVD
Mailing Address - Street 2:
Mailing Address - City:FORT DRUM
Mailing Address - State:NY
Mailing Address - Zip Code:13602-5438
Mailing Address - Country:US
Mailing Address - Phone:315-772-9292
Mailing Address - Fax:
Practice Address - Street 1:11050 MOUNT BELVEDERE BOULEVARD
Practice Address - Street 2:
Practice Address - City:FORT DRUM
Practice Address - State:NY
Practice Address - Zip Code:13602-5004
Practice Address - Country:US
Practice Address - Phone:315-772-9292
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-08-09
Last Update Date:2020-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY42753207Q00000X
390200000X
KYR1579207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100051470Medicaid
KYP00790651Medicare PIN
KY00503027Medicare PIN
KY00280084Medicare PIN
KY03750101Medicare PIN