Provider Demographics
NPI:1073899225
Name:GASAWAY, REANELL (PA)
Entity Type:Individual
Prefix:
First Name:REANELL
Middle Name:
Last Name:GASAWAY
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:71 DELISLE AVE
Mailing Address - Street 2:
Mailing Address - City:ROOSEVELT
Mailing Address - State:NY
Mailing Address - Zip Code:11575-2442
Mailing Address - Country:US
Mailing Address - Phone:909-648-5023
Mailing Address - Fax:
Practice Address - Street 1:71 DELISLE AVE
Practice Address - Street 2:
Practice Address - City:ROOSEVELT
Practice Address - State:NY
Practice Address - Zip Code:11575-2442
Practice Address - Country:US
Practice Address - Phone:909-648-5023
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-11-01
Last Update Date:2012-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY015415363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant