Provider Demographics
NPI:1710952510
Name:DREVITSON, KATHLEEN A (CRNFA)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:A
Last Name:DREVITSON
Suffix:
Gender:F
Credentials:CRNFA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 34864
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85067-4864
Mailing Address - Country:US
Mailing Address - Phone:602-744-4760
Mailing Address - Fax:602-744-4799
Practice Address - Street 1:1850 N CENTRAL AVE
Practice Address - Street 2:SUITE 1600
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85004-4527
Practice Address - Country:US
Practice Address - Phone:602-744-4760
Practice Address - Fax:602-744-4799
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-23
Last Update Date:2010-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZRN016586363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ188161Medicaid
AZAZ0162510OtherBXBS