Healthcare Provider Details

I. General information

NPI: 1356837603
Provider Name (Legal Business Name): DAVID REAVIS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/10/2018
Last Update Date: 07/10/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 MERCY WAY
JOPLIN MO
64804-4524
US

IV. Provider business mailing address

6225 N STATE HIGHWAY 161 STE 200
IRVING TX
75038-2241
US

V. Phone/Fax

Practice location:
  • Phone: 417-556-3729
  • Fax:
Mailing address:
  • Phone: 214-687-0496
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number2018024764
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: