Provider Demographics
NPI:1437856002
Name:REVETTE, ZACHARY (PA)
Entity type:Individual
Prefix:
First Name:ZACHARY
Middle Name:
Last Name:REVETTE
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:140 W 6TH ST STE 210
Mailing Address - Street 2:
Mailing Address - City:OSWEGO
Mailing Address - State:NY
Mailing Address - Zip Code:13126-2554
Mailing Address - Country:US
Mailing Address - Phone:315-349-5800
Mailing Address - Fax:315-349-5785
Practice Address - Street 1:140 W 6TH ST STE 210
Practice Address - Street 2:
Practice Address - City:OSWEGO
Practice Address - State:NY
Practice Address - Zip Code:13126-2554
Practice Address - Country:US
Practice Address - Phone:315-349-5800
Practice Address - Fax:315-349-5800
Is Sole Proprietor?:No
Enumeration Date:2023-02-14
Last Update Date:2025-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NY033090363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program