Provider Demographics
NPI:1710358296
Name:NAIR-RAGHAVAN, REVATHI (PA-C)
Entity type:Individual
Prefix:MRS
First Name:REVATHI
Middle Name:
Last Name:NAIR-RAGHAVAN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:111 EAST 210TH STREET
Mailing Address - Street 2:GROUND FLOOR, GOLD ZONE
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10467-2940
Mailing Address - Country:US
Mailing Address - Phone:718-920-5440
Mailing Address - Fax:718-863-5763
Practice Address - Street 1:111 EAST 210TH STREET
Practice Address - Street 2:GROUND FLOOR, GOLD ZONE
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10467-2940
Practice Address - Country:US
Practice Address - Phone:718-920-5440
Practice Address - Fax:718-863-5763
Is Sole Proprietor?:No
Enumeration Date:2015-10-09
Last Update Date:2024-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY019039363A00000X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant