Provider Demographics
NPI:1144792854
Name:REYES, RAFAEL (SA-C)
Entity Type:Individual
Prefix:
First Name:RAFAEL
Middle Name:
Last Name:REYES
Suffix:
Gender:M
Credentials:SA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14809 88TH AVE APT 2A
Mailing Address - Street 2:
Mailing Address - City:JAMAICA
Mailing Address - State:NY
Mailing Address - Zip Code:11435-3424
Mailing Address - Country:US
Mailing Address - Phone:646-301-0819
Mailing Address - Fax:
Practice Address - Street 1:14809 88TH AVE APT 2A
Practice Address - Street 2:
Practice Address - City:JAMAICA
Practice Address - State:NY
Practice Address - Zip Code:11435-3424
Practice Address - Country:US
Practice Address - Phone:646-301-0819
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-19
Last Update Date:2018-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY18-383246ZC0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant