Provider Demographics
NPI:1568102952
Name:REESE, MARYETTA A (PA)
Entity Type:Individual
Prefix:
First Name:MARYETTA
Middle Name:A
Last Name:REESE
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:301 RIVERVIEW AVE STE 700
Mailing Address - Street 2:
Mailing Address - City:NORFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23510-1065
Mailing Address - Country:US
Mailing Address - Phone:757-252-9365
Mailing Address - Fax:757-962-7217
Practice Address - Street 1:301 RIVERVIEW AVE STE 700
Practice Address - Street 2:
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23510-1065
Practice Address - Country:US
Practice Address - Phone:757-252-9365
Practice Address - Fax:757-962-7217
Is Sole Proprietor?:No
Enumeration Date:2022-04-01
Last Update Date:2023-11-16
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
VA0110008369208G00000X, 363A00000X, 363AS0400X
363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical