Healthcare Provider Details

I. General information

NPI: 1710406590
Provider Name (Legal Business Name): JORDAN LEE REINER PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/13/2017
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12499 UNIVERSITY AVE STE 210
CLIVE IA
50325-8288
US

IV. Provider business mailing address

12499 UNIVERSITY AVE STE 210
CLIVE IA
50325-8288
US

V. Phone/Fax

Practice location:
  • Phone: 515-440-2676
  • Fax: 515-440-2677
Mailing address:
  • Phone: 515-440-2676
  • Fax: 515-440-2677

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number087835
License Number StateIA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: