Provider Demographics
NPI:1487939989
Name:TERAN, RAFAEL ROMAN (FNP)
Entity type:Individual
Prefix:
First Name:RAFAEL
Middle Name:ROMAN
Last Name:TERAN
Suffix:
Gender:M
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2576 S DUKE AVE
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93727-8831
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2576 S DUKE AVE
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93727-8831
Practice Address - Country:US
Practice Address - Phone:559-123-4567
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-10-15
Last Update Date:2015-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20891163WG0000X, 364SF0001X
CANP20891363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163WG0000XNursing Service ProvidersRegistered NurseGeneral Practice
No364SF0001XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistFamily Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ21572ZOtherGRP PTAN FOR BAZ ALLERGY, ASTHMA & SINUS CENTER
CAGR0043790Medicaid