Provider Demographics
NPI: | 1497245062 |
---|---|
Name: | RALEY, CHRISTOPHER PATRICK |
Entity Type: | Individual |
Prefix: | MR |
First Name: | CHRISTOPHER |
Middle Name: | PATRICK |
Last Name: | RALEY |
Suffix: | |
Gender: | M |
Credentials: | |
Other - Prefix: | |
Other - First Name: | |
Other - Middle Name: | |
Other - Last Name: | |
Other - Suffix: | |
Other - Last Name Type: | |
Other - Credentials: | |
Mailing Address - Street 1: | 3607 LEGEND OAKS DR |
Mailing Address - Street 2: | |
Mailing Address - City: | AMELIA |
Mailing Address - State: | OH |
Mailing Address - Zip Code: | 45102-1267 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 513-502-7219 |
Mailing Address - Fax: | |
Practice Address - Street 1: | 2123 AUBURN AVE STE 201 |
Practice Address - Street 2: | |
Practice Address - City: | CINCINNATI |
Practice Address - State: | OH |
Practice Address - Zip Code: | 45219 |
Practice Address - Country: | US |
Practice Address - Phone: | 513-206-1170 |
Practice Address - Fax: | 513-206-1172 |
Is Sole Proprietor?: | Yes |
Enumeration Date: | 2018-05-18 |
Last Update Date: | 2018-08-21 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
OH | RN.308327 | 163W00000X |
OH | RN308327 | 163W00000X |
OH | CNP.023425 | 363LF0000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization | Group |
---|---|---|---|---|---|
Yes | 363LF0000X | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | |
No | 163W00000X | Nursing Service Providers | Registered Nurse | Group - Single Specialty |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
OH | 0307916 | Medicaid |