Healthcare Provider Details

I. General information

NPI: 1932183084
Provider Name (Legal Business Name): NATHAN REYELTS PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/02/2005
Last Update Date: 09/01/2020
Certification Date: 09/01/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1950 CENTER CREEK DR SUITE 100
FAIRMONT MN
56031-3428
US

IV. Provider business mailing address

1950 CENTER CREEK DR SUITE 100
FAIRMONT MN
56031-3428
US

V. Phone/Fax

Practice location:
  • Phone: 507-238-4968
  • Fax:
Mailing address:
  • Phone: 507-238-4968
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number9910
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: