Provider Demographics
NPI:1447761085
Name:AVELLA, TREVOR W (PA-C)
Entity Type:Individual
Prefix:
First Name:TREVOR
Middle Name:W
Last Name:AVELLA
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 1:15300 WEST AVE STE 122
Mailing Address - Street 2:
Mailing Address - City:ORLAND PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60462-4508
Mailing Address - Country:US
Mailing Address - Phone:708-923-4400
Mailing Address - Fax:708-923-4421
Practice Address - Street 1:15300 WEST AVE STE 122
Practice Address - Street 2:
Practice Address - City:ORLAND PARK
Practice Address - State:IL
Practice Address - Zip Code:60462-4508
Practice Address - Country:US
Practice Address - Phone:708-923-4400
Practice Address - Fax:708-923-4421
Is Sole Proprietor?:No
Enumeration Date:2017-10-23
Last Update Date:2024-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085006407363AS0400X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical