Basic Information
| Provider Information | |||||||||
| NPI: | 1750674164 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | REVELS | ||||||||
| FirstName: | JONATHAN | ||||||||
| MiddleName: | W | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 50095 | ||||||||
| Address2: | |||||||||
| City: | SEATTLE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 981455095 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2065205700 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2211 LOMAS BLVD NE | ||||||||
| Address2: | |||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871062719 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5052721476 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/17/2011 | ||||||||
| LastUpdateDate: | 02/22/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | A-2207-19 | NM | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0202X | OP60730003 | WA | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 1750674164 | 05 | WA | MEDICAID |