Healthcare Provider Details

I. General information

NPI: 1790424976
Provider Name (Legal Business Name): MONIQUE REINA REAGAN PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/03/2022
Last Update Date: 11/04/2023
Certification Date: 11/04/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 NE 8TH ST
GRESHAM OR
97030-7317
US

IV. Provider business mailing address

435 N 5TH ST
PHOENIX AZ
85004-2157
US

V. Phone/Fax

Practice location:
  • Phone: 503-988-5155
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberPA213682
License Number StateOR

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: