Provider Demographics
NPI:1508026089
Name:REVENSON, EMILY A (PAC)
Entity Type:Individual
Prefix:
First Name:EMILY
Middle Name:A
Last Name:REVENSON
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1000 BOULDERS PKWY
Mailing Address - Street 2:SUITE 102
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23225-5545
Mailing Address - Country:US
Mailing Address - Phone:804-320-4243
Mailing Address - Fax:804-622-0552
Practice Address - Street 1:6600 W BROAD ST STE 300
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23230-1710
Practice Address - Country:US
Practice Address - Phone:804-320-4243
Practice Address - Fax:804-622-0552
Is Sole Proprietor?:No
Enumeration Date:2008-06-10
Last Update Date:2021-05-20
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
VA0110002789363A00000X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAMC10350Medicare PIN