Provider Demographics
NPI:1043237134
Name:RAVELLA, EILEEN M (PA-C)
Entity Type:Individual
Prefix:
First Name:EILEEN
Middle Name:M
Last Name:RAVELLA
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:PO BOX 3360
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97208-3360
Mailing Address - Country:US
Mailing Address - Phone:866-747-2455
Mailing Address - Fax:
Practice Address - Street 1:413 LILLY RD NE
Practice Address - Street 2:PROVIDENCE ST PETER INTERVENTIONAL RADIOLOGY
Practice Address - City:OLYMPIA
Practice Address - State:WA
Practice Address - Zip Code:98506-5133
Practice Address - Country:US
Practice Address - Phone:360-491-9480
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-16
Last Update Date:2021-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK502363A00000X
WAPA10005223363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKR10971Medicare UPIN