Healthcare Provider Details

I. General information

NPI: 1801750906
Provider Name (Legal Business Name): JOHN REAGAN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/12/2025
Last Update Date: 12/28/2025
Certification Date: 12/28/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 NORTH GRAND BLVD
SAINT LOUIS MO
63103
US

IV. Provider business mailing address

2442 CRIPPLE CREEK DR
SAINT LOUIS MO
63129-5039
US

V. Phone/Fax

Practice location:
  • Phone: 800-758-3678
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: