Basic Information
| Provider Information | |||||||||
| NPI: | 1710581798 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | RAFFERTY | ||||||||
| FirstName: | RYAN | ||||||||
| MiddleName: | SCOTT | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 301 LIPPINCOTT DR STE 410 | ||||||||
| Address2: | |||||||||
| City: | MARLTON | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 080534197 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8565463900 | ||||||||
| FaxNumber: | 8565463908 | ||||||||
| Practice Location | |||||||||
| Address1: | 120 WHITE HORSE PIKE STE 103B | ||||||||
| Address2: | |||||||||
| City: | HADDON HEIGHTS | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 080351938 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8565463900 | ||||||||
| FaxNumber: | 8565463908 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/30/2020 | ||||||||
| LastUpdateDate: | 09/15/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/15/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | MA061962 | PA | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363AS0400X | 25MP00602500 | NJ | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical |
No ID Information.