Healthcare Provider Details

I. General information

NPI: 1619311974
Provider Name (Legal Business Name): REGGIE MICHAEL GILLINS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/17/2013
Last Update Date: 09/23/2025
Certification Date: 09/23/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

355 N MAIN ST
KANAB UT
84741-3260
US

IV. Provider business mailing address

PO BOX 5010
MINOT ND
58702-5010
US

V. Phone/Fax

Practice location:
  • Phone: 435-644-4100
  • Fax: 435-644-3366
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberR42548
License Number StateND
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number7013719-4405
License Number StateUT
# 3
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberTAP4963
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: