Provider Demographics
NPI:1548455405
Name:REVELES, DIANA MARIZA (PA)
Entity type:Individual
Prefix:
First Name:DIANA
Middle Name:MARIZA
Last Name:REVELES
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:DIANA
Other - Middle Name:MARIZA
Other - Last Name:MCMAHAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:823 GATEWAY CENTER WAY
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92102-4541
Mailing Address - Country:US
Mailing Address - Phone:619-515-2300
Mailing Address - Fax:619-906-4564
Practice Address - Street 1:352 L ST
Practice Address - Street 2:
Practice Address - City:CHULA VISTA
Practice Address - State:CA
Practice Address - Zip Code:91911-1208
Practice Address - Country:US
Practice Address - Phone:619-515-2325
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-09-12
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA19306363A00000X
PA19306363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant