Provider Demographics
NPI:1376020941
Name:ROSSON, RAIFORD PATRICK III (APN)
Entity Type:Individual
Prefix:MR
First Name:RAIFORD
Middle Name:PATRICK
Last Name:ROSSON
Suffix:III
Gender:M
Credentials:APN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1649 W BALMORAL AVE APT 2
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60640-1121
Mailing Address - Country:US
Mailing Address - Phone:803-439-3600
Mailing Address - Fax:
Practice Address - Street 1:251 E HURON ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60611-3055
Practice Address - Country:US
Practice Address - Phone:312-695-6252
Practice Address - Fax:312-695-5747
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-25
Last Update Date:2018-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209016509363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care