Provider Demographics
NPI:1881456093
Name:RAYMOND, LOUIS JACQUES (PA)
Entity type:Individual
Prefix:
First Name:LOUIS
Middle Name:JACQUES
Last Name:RAYMOND
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1820 E BELL DE MAR DR APT 137
Mailing Address - Street 2:
Mailing Address - City:TEMPE
Mailing Address - State:AZ
Mailing Address - Zip Code:85283-5738
Mailing Address - Country:US
Mailing Address - Phone:646-255-3974
Mailing Address - Fax:
Practice Address - Street 1:2270 S RIDGEVIEW DR STE 204
Practice Address - Street 2:
Practice Address - City:YUMA
Practice Address - State:AZ
Practice Address - Zip Code:85364-8880
Practice Address - Country:US
Practice Address - Phone:646-255-3974
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-24
Last Update Date:2024-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ10128363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant