Provider Demographics
NPI:1528712668
Name:RAYBURN, JUSTICE MYKEL
Entity type:Individual
Prefix:
First Name:JUSTICE
Middle Name:MYKEL
Last Name:RAYBURN
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 1:102 STINARD AVE
Mailing Address - Street 2:
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13207-1242
Mailing Address - Country:US
Mailing Address - Phone:315-246-3989
Mailing Address - Fax:
Practice Address - Street 1:1661 VALLEY DR
Practice Address - Street 2:
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13207-2853
Practice Address - Country:US
Practice Address - Phone:315-246-3989
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-08
Last Update Date:2022-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
579482489172A00000X
NY579482489172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver