Healthcare Provider Details

I. General information

NPI: 1174552970
Provider Name (Legal Business Name): RAPHAEL VASSOR P.A.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/02/2006
Last Update Date: 06/22/2026
Certification Date: 06/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

830 JEFFERSON AVE
REDWOOD CITY CA
94063-1804
US

IV. Provider business mailing address

2113 RESTON CIR
ROYAL PALM BEACH FL
33411-6111
US

V. Phone/Fax

Practice location:
  • Phone: 650-381-0616
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA9101540
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number62812
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: