Healthcare Provider Details

I. General information

NPI: 1164460671
Provider Name (Legal Business Name): SHELLEY L REICHMUTH PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: SHELLEY L FISCHER PA-C

II. Dates (important events)

Enumeration Date: 06/04/2006
Last Update Date: 08/01/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8303 DODGE ST SUITE 225
OMAHA NE
68114-4108
US

IV. Provider business mailing address

8303 DODGE ST SUITE 225
OMAHA NE
68114-4108
US

V. Phone/Fax

Practice location:
  • Phone: 402-354-5860
  • Fax: 402-354-2350
Mailing address:
  • Phone: 402-354-5860
  • Fax: 402-354-2350

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number1314
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: