Healthcare Provider Details

I. General information

NPI: 1124210265
Provider Name (Legal Business Name): KRISTINA LIZETTE REEVES PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/13/2007
Last Update Date: 07/18/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1817 CYPRESS BROOK DR SUITE 101
TRINITY FL
34655-4416
US

IV. Provider business mailing address

5116 W CLEVELAND ST
TAMPA FL
33609-3504
US

V. Phone/Fax

Practice location:
  • Phone: 727-834-8377
  • Fax:
Mailing address:
  • Phone: 813-857-8974
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA 9104215
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: