Provider Demographics
NPI:1568230456
Name:RAVENCREST MEDICAL
Entity Type:Organization
Organization Name:RAVENCREST MEDICAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN ASSISTANT/ OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:DANNA
Authorized Official - Middle Name:MAVIS CONSTANCE
Authorized Official - Last Name:MOISII
Authorized Official - Suffix:
Authorized Official - Credentials:PA-C
Authorized Official - Phone:907-252-9216
Mailing Address - Street 1:35670 KENAI SPUR HWY STE 102
Mailing Address - Street 2:
Mailing Address - City:SOLDOTNA
Mailing Address - State:AK
Mailing Address - Zip Code:99669-7649
Mailing Address - Country:US
Mailing Address - Phone:907-252-9216
Mailing Address - Fax:
Practice Address - Street 1:35670 KENAI SPUR HWY STE 102
Practice Address - Street 2:
Practice Address - City:SOLDOTNA
Practice Address - State:AK
Practice Address - Zip Code:99669-7649
Practice Address - Country:US
Practice Address - Phone:907-252-9216
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-12-19
Last Update Date:2024-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty