Provider Demographics
NPI:1790341618
Name:REVENKO, CASEY S (PHYSICIAN ASSISTANT)
Entity Type:Individual
Prefix:
First Name:CASEY
Middle Name:S
Last Name:REVENKO
Suffix:
Gender:F
Credentials:PHYSICIAN ASSISTANT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2525 GOLDEN RAIN RD APT 5
Mailing Address - Street 2:
Mailing Address - City:WALNUT CREEK
Mailing Address - State:CA
Mailing Address - Zip Code:94595-1938
Mailing Address - Country:US
Mailing Address - Phone:925-360-2025
Mailing Address - Fax:
Practice Address - Street 1:2999 REGENT ST STE 225
Practice Address - Street 2:
Practice Address - City:BERKELEY
Practice Address - State:CA
Practice Address - Zip Code:94705-2117
Practice Address - Country:US
Practice Address - Phone:510-704-7760
Practice Address - Fax:510-704-7765
Is Sole Proprietor?:No
Enumeration Date:2019-05-15
Last Update Date:2019-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA56633207XX0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports Medicine