Provider Demographics
NPI:1629590583
Name:RAVENELL, TRINA NICOLE (PA-C)
Entity Type:Individual
Prefix:
First Name:TRINA
Middle Name:NICOLE
Last Name:RAVENELL
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 1:300 E MCBEE AVE FL 4
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29601-2842
Mailing Address - Country:US
Mailing Address - Phone:864-522-8611
Mailing Address - Fax:
Practice Address - Street 1:200 PATEWOOD DR STE B400
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29615-6306
Practice Address - Country:US
Practice Address - Phone:864-454-4368
Practice Address - Fax:864-241-9232
Is Sole Proprietor?:No
Enumeration Date:2017-07-12
Last Update Date:2021-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCTL2783363AM0700X
SC2783363A00000X
SCMPA2783TL363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCMPA2783TLOtherSC BOARD OF MEDICAL EXAMINERS
SC3026PAMedicaid
SCSCA853OtherMEDICARE