Provider Demographics
NPI:1417577537
Name:TREVINO, EDUARDO (PA)
Entity Type:Individual
Prefix:
First Name:EDUARDO
Middle Name:
Last Name:TREVINO
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3201 W PEORIA AVE STE D700
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85029-4612
Mailing Address - Country:US
Mailing Address - Phone:602-863-1716
Mailing Address - Fax:
Practice Address - Street 1:3201 W PEORIA AVE STE D700
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85029-4612
Practice Address - Country:US
Practice Address - Phone:602-863-1716
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-18
Last Update Date:2023-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN2543453OtherINDIVIDUAL