Healthcare Provider Details

I. General information

NPI: 1255453403
Provider Name (Legal Business Name): BONNIE K. REVERE P.A.-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/06/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

411 OAK ST
CINCINNATI OH
45219-2598
US

IV. Provider business mailing address

411 OAK ST
CINCINNATI OH
45219-2598
US

V. Phone/Fax

Practice location:
  • Phone: 513-984-1800
  • Fax: 513-984-4909
Mailing address:
  • Phone: 513-984-1800
  • Fax: 513-984-4909

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA00350
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: