Provider Demographics
NPI:1346570322
Name:REVZIN, GINA (PA,)
Entity Type:Individual
Prefix:MRS
First Name:GINA
Middle Name:
Last Name:REVZIN
Suffix:
Gender:F
Credentials:PA,
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:660 WHITE PLAINS RD
Mailing Address - Street 2:
Mailing Address - City:TARRYTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:10591-5139
Mailing Address - Country:US
Mailing Address - Phone:914-333-5801
Mailing Address - Fax:
Practice Address - Street 1:627 BROADWAY STE 1
Practice Address - Street 2:
Practice Address - City:MASSAPEQUA
Practice Address - State:NY
Practice Address - Zip Code:11758-5031
Practice Address - Country:US
Practice Address - Phone:516-541-4171
Practice Address - Fax:516-377-5712
Is Sole Proprietor?:No
Enumeration Date:2010-01-13
Last Update Date:2022-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY009155363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical