Provider Demographics
NPI:1326410044
Name:RAFFERTY, BRYAN (PA-C)
Entity Type:Individual
Prefix:
First Name:BRYAN
Middle Name:
Last Name:RAFFERTY
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 1:88MDG/SGGP
Mailing Address - Street 2:4881 SUGAR MAPLE DR
Mailing Address - City:WPAFB
Mailing Address - State:OH
Mailing Address - Zip Code:45433
Mailing Address - Country:US
Mailing Address - Phone:937-713-9011
Mailing Address - Fax:
Practice Address - Street 1:88MDG/SGGP
Practice Address - Street 2:4881 SUGAR MAPLE DR
Practice Address - City:WPAFB
Practice Address - State:OH
Practice Address - Zip Code:45433
Practice Address - Country:US
Practice Address - Phone:937-713-9011
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-10-21
Last Update Date:2022-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN2881363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ019535Medicaid
TN103I979425Medicare PIN