Provider Demographics
NPI:1023194750
Name:REAVES, FREDERICK C (PA)
Entity Type:Individual
Prefix:
First Name:FREDERICK
Middle Name:C
Last Name:REAVES
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 634748
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45263-0042
Mailing Address - Country:US
Mailing Address - Phone:239-337-7700
Mailing Address - Fax:904-346-0113
Practice Address - Street 1:2727 WINKLER AVE
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33901-9358
Practice Address - Country:US
Practice Address - Phone:239-939-8611
Practice Address - Fax:904-346-0113
Is Sole Proprietor?:No
Enumeration Date:2006-10-27
Last Update Date:2009-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9103819363A00000X
CAPA12718363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1023194750Medicaid
FLP23540Medicare UPIN
FLAB403YMedicare PIN
CABH080ZMedicare PIN
FLAB403ZMedicare PIN