Provider Demographics
NPI:1760810188
Name:STUCCIO, RAPHAEL
Entity Type:Individual
Prefix:
First Name:RAPHAEL
Middle Name:
Last Name:STUCCIO
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 1:13 JANE LACEY DR APT A
Mailing Address - Street 2:
Mailing Address - City:ENDICOTT
Mailing Address - State:NY
Mailing Address - Zip Code:13760-3723
Mailing Address - Country:US
Mailing Address - Phone:570-574-4791
Mailing Address - Fax:
Practice Address - Street 1:156 CORLISS AVE
Practice Address - Street 2:
Practice Address - City:JOHNSON CITY
Practice Address - State:NY
Practice Address - Zip Code:13790-2060
Practice Address - Country:US
Practice Address - Phone:607-763-6735
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-10-22
Last Update Date:2013-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY650570-1367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered