Provider Demographics
NPI:1710062682
Name:VIJAYARAGHAVAN, REVATHI (PA)
Entity Type:Individual
Prefix:MRS
First Name:REVATHI
Middle Name:
Last Name:VIJAYARAGHAVAN
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19 DAREWOOD LN
Mailing Address - Street 2:
Mailing Address - City:VALLEY STREAM
Mailing Address - State:NY
Mailing Address - Zip Code:11581-2407
Mailing Address - Country:US
Mailing Address - Phone:516-792-3789
Mailing Address - Fax:
Practice Address - Street 1:19 DAREWOOD LN
Practice Address - Street 2:
Practice Address - City:VALLEY STREAM
Practice Address - State:NY
Practice Address - Zip Code:11581-2407
Practice Address - Country:US
Practice Address - Phone:516-792-3789
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY007222363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical