Basic Information
| Provider Information | |||||||||
| NPI: | 1992306781 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | RAYBURN | ||||||||
| FirstName: | ERIC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 30 GREAT OAK RD | ||||||||
| Address2: | |||||||||
| City: | LEVITTOWN | ||||||||
| State: | PA | ||||||||
| PostalCode: | 190573314 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2155957154 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1600 HADDON AVE | ||||||||
| Address2: | |||||||||
| City: | CAMDEN | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 081033101 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8567573500 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/06/2020 | ||||||||
| LastUpdateDate: | 11/06/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/06/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | 134223 | NJ | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered | 363L00000X | 26NJ01074400 | NJ | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
No ID Information.