Provider Demographics
NPI:1710506019
Name:SAMANIEGO, RAPHAEL
Entity Type:Individual
Prefix:MR
First Name:RAPHAEL
Middle Name:
Last Name:SAMANIEGO
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 1:1297 FRANKLIN ST
Mailing Address - Street 2:
Mailing Address - City:COQUITLAU
Mailing Address - State:BRITISH COLUMBIA
Mailing Address - Zip Code:V3B 6N6
Mailing Address - Country:CA
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1400 PELHAM PARKWAY S.
Practice Address - Street 2:
Practice Address - City:BROX
Practice Address - State:NY
Practice Address - Zip Code:10461
Practice Address - Country:US
Practice Address - Phone:718-918-3419
Practice Address - Fax:718-918-6147
Is Sole Proprietor?:No
Enumeration Date:2020-04-16
Last Update Date:2020-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program