MEDICARE: MRS. REVATHI VIJAYARAGHAVAN P.A.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363AM0700X	Medical Physician Assistant	007222	NY

General Provider Information

NPI Number	:	1710062682
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. REVATHI VIJAYARAGHAVAN P.A.

Provider Business Mailing Address
First Line	:	19 DAREWOOD LN
Second Line	:
City	:	VALLEY STREAM
State	:	NY
Zip	:	11581-2407
Country	:	US
Telephone Number	:	516-792-3789
Fax Number	:

Provider Business Practice Location Address
First Line	:	19 DAREWOOD LN
Second Line	:
City	:	VALLEY STREAM
State	:	NY
Zip	:	11581-2407
Country	:	US
Telephone Number	:	516-792-3789
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/26/2006
Last Update Date	:	07/08/2007

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