Provider Demographics
NPI:1568455616
Name:DUNNAHOO, REAGAN R (PA)
Entity Type:Individual
Prefix:
First Name:REAGAN
Middle Name:R
Last Name:DUNNAHOO
Suffix:
Gender:F
Credentials:PA
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 5719
Mailing Address - Street 2:
Mailing Address - City:ATHENS
Mailing Address - State:GA
Mailing Address - Zip Code:30604-5719
Mailing Address - Country:US
Mailing Address - Phone:706-354-5770
Mailing Address - Fax:706-354-5769
Practice Address - Street 1:2450 S TELSHOR BLVD
Practice Address - Street 2:
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88011-5069
Practice Address - Country:US
Practice Address - Phone:706-354-5770
Practice Address - Fax:706-354-5769
Is Sole Proprietor?:No
Enumeration Date:2005-08-24
Last Update Date:2011-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM96-PA02363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMH6226Medicaid
S73173Medicare UPIN
NMNM301755Medicare PIN
NMNM301306Medicare PIN