Provider Demographics
NPI:1477536456
Name:IMAN, REGINA LOUISE (APRN,BC,ANP)
Entity Type:Individual
Prefix:MS
First Name:REGINA
Middle Name:LOUISE
Last Name:IMAN
Suffix:
Gender:F
Credentials:APRN,BC,ANP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 23340
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63156-3340
Mailing Address - Country:US
Mailing Address - Phone:314-739-4166
Mailing Address - Fax:314-739-2485
Practice Address - Street 1:1000 DES PERES RD
Practice Address - Street 2:SUITE 300
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63131-2050
Practice Address - Country:US
Practice Address - Phone:314-919-2600
Practice Address - Fax:314-919-2677
Is Sole Proprietor?:No
Enumeration Date:2005-11-23
Last Update Date:2016-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOMO2002025105363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO152800301Medicare PIN
MO828134160Medicare PIN