Healthcare Provider Details

I. General information

NPI: 1144269374
Provider Name (Legal Business Name): PAUL L REESE PA
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 06/05/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

323 S MINNESOTA ST
CROOKSTON MN
56716-1601
US

IV. Provider business mailing address

10718 440TH ST SE
FERTILE MN
56540-9160
US

V. Phone/Fax

Practice location:
  • Phone: 218-281-9595
  • Fax:
Mailing address:
  • Phone: 218-945-6036
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number9050
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: