Healthcare Provider Details

I. General information

NPI: 1013840024
Provider Name (Legal Business Name): MIRIAM RAITPORT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/08/2026
Last Update Date: 06/18/2026
Certification Date: 06/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

225 EASTVIEW DR
CENTRAL ISLIP NY
11722-4539
US

IV. Provider business mailing address

678 CROWN ST
BROOKLYN NY
11213-5304
US

V. Phone/Fax

Practice location:
  • Phone: --
  • Fax:
Mailing address:
  • Phone: 646-416-2233
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: