Provider Demographics
NPI:1568943058
Name:REZVIN, EKATERINA M (PA-C)
Entity Type:Individual
Prefix:
First Name:EKATERINA
Middle Name:M
Last Name:REZVIN
Suffix:
Gender:F
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 1:1680 ROUTE 23 STE 250
Mailing Address - Street 2:
Mailing Address - City:WAYNE
Mailing Address - State:NJ
Mailing Address - Zip Code:07470-7520
Mailing Address - Country:US
Mailing Address - Phone:973-633-1122
Mailing Address - Fax:973-832-7550
Practice Address - Street 1:1680 ROUTE 23 STE 250
Practice Address - Street 2:
Practice Address - City:WAYNE
Practice Address - State:NJ
Practice Address - Zip Code:07470-7520
Practice Address - Country:US
Practice Address - Phone:973-633-1122
Practice Address - Fax:973-832-7550
Is Sole Proprietor?:No
Enumeration Date:2018-08-23
Last Update Date:2020-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY022526363AS0400X
NJ25MP00496000363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY022526OtherLICENSE