Provider Demographics
NPI:1326073982
Name:PEXA, REVI D (PA-C)
Entity Type:Individual
Prefix:MR
First Name:REVI
Middle Name:D
Last Name:PEXA
Suffix:
Gender:M
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 1:1776 N SCOTTSDALE RD #368
Mailing Address - Street 2:
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85252
Mailing Address - Country:US
Mailing Address - Phone:480-201-5264
Mailing Address - Fax:480-393-1970
Practice Address - Street 1:1776 N SCOTTSDALE RD UNIT 368
Practice Address - Street 2:
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85252-3616
Practice Address - Country:US
Practice Address - Phone:480-201-5264
Practice Address - Fax:480-393-1970
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-12
Last Update Date:2017-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ2473363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ470295Medicaid
AZ470295Medicaid
AZS82882Medicare UPIN
AZ102372Medicare PIN
AZZ125540Medicare PIN