Basic Information
| Provider Information | |||||||||
| NPI: | 1326013152 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | NEISWONGER | ||||||||
| FirstName: | RAYMOND | ||||||||
| MiddleName: | ARTHUR | ||||||||
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| Credential: | RN, ACNP, BC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6653 MAIN STREET | ||||||||
| Address2: | |||||||||
| City: | WILLIAMSVILLE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 14221 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7162044500 | ||||||||
| FaxNumber: | 7162044501 | ||||||||
| Practice Location | |||||||||
| Address1: | 462 GRIDER STREET | ||||||||
| Address2: | RM 741 | ||||||||
| City: | BUFFALO | ||||||||
| State: | NY | ||||||||
| PostalCode: | 14215 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7169616995 | ||||||||
| FaxNumber: | 7168985276 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/23/2006 | ||||||||
| LastUpdateDate: | 10/21/2009 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LC0200X | F430228-1 | NY | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Critical Care Medicine |
ID Information
| ID | Type | State | Issuer | Description | 02663761 | 05 | NY | MEDICAID |