Healthcare Provider Details

I. General information

NPI: 1427165836
Provider Name (Legal Business Name): DIANE M REEVES PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/23/2006
Last Update Date: 05/23/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 HEALTH SERVICE DR. KYLE I.H.S. OUT PATIENT CLINIC
KYLE SD
57752
US

IV. Provider business mailing address

1000 HEALTH SERVICE DR. KYLE I.H.S. OUT PATIENT CLINIC
KYLE SD
57752
US

V. Phone/Fax

Practice location:
  • Phone: 605-455-2451
  • Fax: 605-455-1529
Mailing address:
  • Phone: 605-455-2451
  • Fax: 605-455-1529

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA03219
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number5601002364
License Number StateMI
# 3
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License Number41808
License Number StateTX
# 4
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License Number5302026024
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: