Provider Demographics
NPI:1073624094
Name:REITAN, ANN M (PA-C)
Entity Type:Individual
Prefix:
First Name:ANN
Middle Name:M
Last Name:REITAN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2041 NE WILLIAMSON CT
Mailing Address - Street 2:STE B
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97701-3925
Mailing Address - Country:US
Mailing Address - Phone:541-323-7456
Mailing Address - Fax:541-323-4997
Practice Address - Street 1:2041 NE WILLIAMSON CT
Practice Address - Street 2:STE B
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97701-3925
Practice Address - Country:US
Practice Address - Phone:541-323-7456
Practice Address - Fax:541-323-4997
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2016-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORPA00487363A00000X
IDPA741363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR00834452OtherMEDICARE RAILROAD
OR500605525Medicaid
OR00834452OtherMEDICARE RAILROAD
ORR86156Medicare UPIN
ID138503Medicare Oscar/Certification
OR500605525Medicaid