Healthcare Provider Details

I. General information

NPI: 1063402568
Provider Name (Legal Business Name): PATRICIA R RAFTERY DO
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 10/26/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

310 W MAIN ST
SPARTA WI
54656-2170
US

IV. Provider business mailing address

310 W MAIN ST
SPARTA WI
54656-2170
US

V. Phone/Fax

Practice location:
  • Phone: 608-269-1770
  • Fax: 608-269-1017
Mailing address:
  • Phone: 608-269-1770
  • Fax: 608-269-1017

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number22609
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: