Provider Demographics
NPI:1548562523
Name:RAQUENO, BRIAN A (PT, DPT)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:A
Last Name:RAQUENO
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9850 19TH ST
Mailing Address - Street 2:APT 186
Mailing Address - City:ALTA LOMA
Mailing Address - State:CA
Mailing Address - Zip Code:91737-4232
Mailing Address - Country:US
Mailing Address - Phone:302-345-2863
Mailing Address - Fax:
Practice Address - Street 1:9850 19TH ST
Practice Address - Street 2:APT 186
Practice Address - City:ALTA LOMA
Practice Address - State:CA
Practice Address - Zip Code:91737-4232
Practice Address - Country:US
Practice Address - Phone:302-345-2863
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-11-24
Last Update Date:2021-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEJ1-0002540225100000X
CA39061225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
DE1548562523OtherDELAWARE PHYSCIANS CARE
DE1548562523Medicaid
DE200389ZB82Medicare PIN