Healthcare Provider Details

I. General information

NPI: 1952054090
Provider Name (Legal Business Name): RAFAEL BACANI ROQUE NP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/29/2022
Last Update Date: 04/12/2023
Certification Date: 04/12/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

150 55TH ST
BROOKLYN NY
11220-2508
US

IV. Provider business mailing address

9255 SHORE RD APT 2C
BROOKLYN NY
11209-6538
US

V. Phone/Fax

Practice location:
  • Phone: 917-679-8317
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberF346423
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: