Individual
MATTHEW CHARLES REVILLA
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
PA-C
Contact information
Practice address
507 PARK ST, PALMETTO, GA 30268-1007
(770) 463-4644
Mailing address
643 MAIN ST, PALMETTO, GA 30268-1138
(404) 929-8824
Taxonomy
Speciality
Code
Description
License number
State
207QA0505X
Adult Medicine Physician
9684
GA
363A00000X
Physician Assistant
Primary
9684
GA
Other
Enumeration date
04/09/2020
Last updated
08/27/2021
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