Provider Demographics
NPI:1730546649
Name:REBILLOT, EVAN T (PA)
Entity type:Individual
Prefix:
First Name:EVAN
Middle Name:T
Last Name:REBILLOT
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:415 BUSHWICK AVE
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11206-3729
Mailing Address - Country:US
Mailing Address - Phone:330-806-7967
Mailing Address - Fax:
Practice Address - Street 1:1300 YORK AVE
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10065-4805
Practice Address - Country:US
Practice Address - Phone:845-926-4968
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-01-22
Last Update Date:2016-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant