Provider Demographics
NPI:1427558154
Name:REID, DESIREE DARLENE (PA-C)
Entity Type:Individual
Prefix:MS
First Name:DESIREE
Middle Name:DARLENE
Last Name:REID
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 1:1024 EAGLE HILLS WAY
Mailing Address - Street 2:
Mailing Address - City:EAGLE
Mailing Address - State:ID
Mailing Address - Zip Code:83616-5216
Mailing Address - Country:US
Mailing Address - Phone:208-409-9471
Mailing Address - Fax:
Practice Address - Street 1:1102 E LOCUST ST
Practice Address - Street 2:
Practice Address - City:EMMETT
Practice Address - State:ID
Practice Address - Zip Code:83617-2713
Practice Address - Country:US
Practice Address - Phone:208-365-6004
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-19
Last Update Date:2018-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPA-1597363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant