Healthcare Provider Details

I. General information

NPI: 1588669428
Provider Name (Legal Business Name): CHARLENE ELAINE REUST PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/16/2005
Last Update Date: 10/17/2018
Certification Date:
Deactivation Date: 07/17/2007
Reactivation Date: 03/18/2008

III. Provider practice location address

1084 NICKERSON ST
WAYNOKA OK
73860
US

IV. Provider business mailing address

5300 N INDEPENDENCE AVE STE 280
OKLAHOMA CITY OK
73112-5555
US

V. Phone/Fax

Practice location:
  • Phone: 580-824-2291
  • Fax: 580-824-0429
Mailing address:
  • Phone: 580-824-2291
  • Fax: 580-824-0429

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number1500390
License Number StateKS
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number2549
License Number StateOK
# 3
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number1500390
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: