Individual
MATTHEW JAMES REVENNAUGH
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
PA
Contact information
Practice address
1400 HIGHLAND RD STE 1, RICHMOND, IN 47374-8810
(765) 935-8905
(765) 939-4200
Mailing address
1100 REID PARKWAY, MEDICAL STAFF SERVICES, RICHMOND, IN 47374
(659) 358-8027
(765) 983-3219
Taxonomy
Speciality
Code
Description
License number
State
363A00000X
Physician Assistant
Primary
10003154A
IN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
300048991
—
IN
Enumeration date
03/04/2021
Last updated
09/22/2021
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