Provider Demographics
NPI:1003381401
Name:RAIOLA, RYAN JOSEPH (PHYSICIAN ASSISTANT)
Entity type:Individual
Prefix:MR
First Name:RYAN
Middle Name:JOSEPH
Last Name:RAIOLA
Suffix:
Gender:M
Credentials:PHYSICIAN ASSISTANT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:243 WATCHOGUE RD
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10314-3189
Mailing Address - Country:US
Mailing Address - Phone:347-558-1455
Mailing Address - Fax:
Practice Address - Street 1:243 WATCHOGUE RD
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10314-3189
Practice Address - Country:US
Practice Address - Phone:347-558-1455
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-11
Last Update Date:2018-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYZA62946CMedicaid