Healthcare Provider Details

I. General information

NPI: 1821617036
Provider Name (Legal Business Name): MATTHEW CHARLES REVILLA PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/09/2020
Last Update Date: 08/27/2021
Certification Date: 08/27/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

507 PARK ST
PALMETTO GA
30268-1007
US

IV. Provider business mailing address

643 MAIN ST
PALMETTO GA
30268-1138
US

V. Phone/Fax

Practice location:
  • Phone: 770-463-4644
  • Fax:
Mailing address:
  • Phone: 404-929-8824
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number9684
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License Number9684
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: