Healthcare Provider Details

I. General information

NPI: 1588316665
Provider Name (Legal Business Name): NICHOLAS ALEXANDER REEVE PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: NICHOLAS PETERS

II. Dates (important events)

Enumeration Date: 01/20/2022
Last Update Date: 08/19/2026
Certification Date: 08/19/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2158 EXCHANGE ST STE 107
ASTORIA OR
97103-3307
US

IV. Provider business mailing address

2111 EXCHANGE ST
ASTORIA OR
97103-3329
US

V. Phone/Fax

Practice location:
  • Phone: 503-338-4675
  • Fax: 503-338-4676
Mailing address:
  • Phone: 503-325-4321
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA210255
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: