Provider Demographics
NPI:1164460671
Name:REICHMUTH, SHELLEY L (PA-C)
Entity Type:Individual
Prefix:
First Name:SHELLEY
Middle Name:L
Last Name:REICHMUTH
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:SHELLEY
Other - Middle Name:L
Other - Last Name:FISCHER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:8303 DODGE ST
Mailing Address - Street 2:SUITE 225
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68114-4108
Mailing Address - Country:US
Mailing Address - Phone:402-354-5860
Mailing Address - Fax:402-354-2350
Practice Address - Street 1:8303 DODGE ST
Practice Address - Street 2:SUITE 225
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68114-4108
Practice Address - Country:US
Practice Address - Phone:402-354-5860
Practice Address - Fax:402-354-2350
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-04
Last Update Date:2013-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE1314363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NEP00872962OtherRAILROAD MEDICARE
NE281030Medicare PIN
NEQ55395Medicare UPIN