Provider Demographics
NPI:1720257223
Name:MARDEKHEH RAFIEI, BABAK (RPA-C)
Entity Type:Individual
Prefix:MR
First Name:BABAK
Middle Name:
Last Name:MARDEKHEH RAFIEI
Suffix:
Gender:M
Credentials:RPA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22 CHAPEL ST
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11201-1903
Mailing Address - Country:US
Mailing Address - Phone:718-260-2962
Mailing Address - Fax:718-522-3186
Practice Address - Street 1:1149-55 MYRTLE AVENUE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NM
Practice Address - Zip Code:11206
Practice Address - Country:US
Practice Address - Phone:718-574-1928
Practice Address - Fax:718-919-2374
Is Sole Proprietor?:No
Enumeration Date:2008-02-28
Last Update Date:2008-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY011285363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY011285OtherNEW YORK STATE