Basic Information
| Provider Information | |||||||||
| NPI: | 1306956248 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | REVAN | ||||||||
| FirstName: | SHARON | ||||||||
| MiddleName: | L. | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 120 W 106TH ST | ||||||||
| Address2: | 4TH FLOOR | ||||||||
| City: | NEW YORK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 100253923 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2128705940 | ||||||||
| FaxNumber: | 2128704905 | ||||||||
| Practice Location | |||||||||
| Address1: | 3 BARKER AVE | ||||||||
| Address2: | 4TH FLOOR | ||||||||
| City: | WHITE PLAINS | ||||||||
| State: | NY | ||||||||
| PostalCode: | 106011509 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9149491199 | ||||||||
| FaxNumber: | 9149491245 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/30/2006 | ||||||||
| LastUpdateDate: | 10/14/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RR0500X | 191108 | NY | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Rheumatology |
ID Information
| ID | Type | State | Issuer | Description | 01666962 | 05 | NY | MEDICAID |