Provider Demographics
NPI:1306005681
Name:REAVIS, DAVID RAUL (PA-C)
Entity Type:Individual
Prefix:MR
First Name:DAVID
Middle Name:RAUL
Last Name:REAVIS
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2480 LIBERTY ST NE
Mailing Address - Street 2:STE 180
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97301-8388
Mailing Address - Country:US
Mailing Address - Phone:503-399-7520
Mailing Address - Fax:503-362-7344
Practice Address - Street 1:875 OAK ST SE
Practice Address - Street 2:STE 3010
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97301
Practice Address - Country:US
Practice Address - Phone:503-399-7520
Practice Address - Fax:503-362-7344
Is Sole Proprietor?:No
Enumeration Date:2008-06-03
Last Update Date:2021-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORPA01357363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500603869Medicaid
WA1306005681Medicaid
OR500603869Medicaid