Healthcare Provider Details

I. General information

NPI: 1235163908
Provider Name (Legal Business Name): MICHAEL JAMES REEVES CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/10/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 ALDER STREET
SOUTH BEND WA
98586
US

IV. Provider business mailing address

800 ALDER STREET PO BOX 438
SOUTH BEND WA
98586
US

V. Phone/Fax

Practice location:
  • Phone: 360-875-5526
  • Fax: 360-875-6167
Mailing address:
  • Phone: 360-875-5526
  • Fax: 360-875-6167

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberAP30004395
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: