Provider Demographics
NPI:1760842512
Name:TREVISANO, JUDITH L (AGNP)
Entity type:Individual
Prefix:
First Name:JUDITH
Middle Name:L
Last Name:TREVISANO
Suffix:
Gender:F
Credentials:AGNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2500 CANYON RD STE A1
Mailing Address - Street 2:
Mailing Address - City:BULLHEAD CITY
Mailing Address - State:AZ
Mailing Address - Zip Code:86442-8492
Mailing Address - Country:US
Mailing Address - Phone:928-704-4499
Mailing Address - Fax:928-704-4949
Practice Address - Street 1:2500 CANYON RD STE A1
Practice Address - Street 2:
Practice Address - City:BULLHEAD CITY
Practice Address - State:AZ
Practice Address - Zip Code:86442-8492
Practice Address - Country:US
Practice Address - Phone:928-704-4499
Practice Address - Fax:928-704-7494
Is Sole Proprietor?:No
Enumeration Date:2016-03-07
Last Update Date:2024-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZTEMP305268363LA2200X
MO2016008575363LP2300X
NVAPRN002329363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV1760842512Medicaid
NV1760842512Medicaid