Healthcare Provider Details

I. General information

NPI: 1528114790
Provider Name (Legal Business Name): MR. RAFAEL ADOLFO BUENO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/28/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1249 5TH AVE
NEW YORK NY
10029-4413
US

IV. Provider business mailing address

41 OXFORD LN
HARRIMAN NY
10926-3008
US

V. Phone/Fax

Practice location:
  • Phone: 212-360-3903
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number005132
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: