Provider Demographics
NPI:1053809954
Name:ROSAS, RAFAEL
Entity type:Individual
Prefix:
First Name:RAFAEL
Middle Name:
Last Name:ROSAS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1712 ISLETA BLVD SW APT 3A
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87105-4752
Mailing Address - Country:US
Mailing Address - Phone:505-918-7959
Mailing Address - Fax:
Practice Address - Street 1:1712 ISLETA BLVD SW APT 3A
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87105-4752
Practice Address - Country:US
Practice Address - Phone:505-918-7959
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-25
Last Update Date:2018-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM3768720716Medicaid