Provider Demographics
NPI:1568906865
Name:RENO, DUSTIN (NP-C)
Entity Type:Individual
Prefix:
First Name:DUSTIN
Middle Name:
Last Name:RENO
Suffix:
Gender:M
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1155 YELLOWSTONE AVE
Mailing Address - Street 2:STE D
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83201-4369
Mailing Address - Country:US
Mailing Address - Phone:208-637-9610
Mailing Address - Fax:208-238-6162
Practice Address - Street 1:1155 YELLOWSTONE AVE
Practice Address - Street 2:STE D
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201-4369
Practice Address - Country:US
Practice Address - Phone:208-637-9610
Practice Address - Fax:208-238-6162
Is Sole Proprietor?:No
Enumeration Date:2016-12-06
Last Update Date:2024-04-23
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
ID54537363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily