Provider Demographics
NPI:1003996232
Name:REVITSKY, PHILENE W (PA-C)
Entity Type:Individual
Prefix:
First Name:PHILENE
Middle Name:W
Last Name:REVITSKY
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:501 PENN AVE
Mailing Address - Street 2:
Mailing Address - City:PITTSBURGH
Mailing Address - State:PA
Mailing Address - Zip Code:15222-3208
Mailing Address - Country:US
Mailing Address - Phone:412-442-2343
Mailing Address - Fax:412-325-2536
Practice Address - Street 1:501 PENN AVE
Practice Address - Street 2:
Practice Address - City:PITTSBURGH
Practice Address - State:PA
Practice Address - Zip Code:15222
Practice Address - Country:US
Practice Address - Phone:412-442-2343
Practice Address - Fax:412-325-2536
Is Sole Proprietor?:No
Enumeration Date:2006-10-16
Last Update Date:2018-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA002441L363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
11673368OtherCAQH
PA103503230Medicaid
PA020154Medicare ID - Type Unspecified