Provider Demographics
NPI:1588669428
Name:REUST, CHARLENE ELAINE (PA)
Entity Type:Individual
Prefix:
First Name:CHARLENE
Middle Name:ELAINE
Last Name:REUST
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 1:5300 N INDEPENDENCE AVE STE 280
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73112-5555
Mailing Address - Country:US
Mailing Address - Phone:580-824-2291
Mailing Address - Fax:580-824-0429
Practice Address - Street 1:1084 NICKERSON ST
Practice Address - Street 2:
Practice Address - City:WAYNOKA
Practice Address - State:OK
Practice Address - Zip Code:73860
Practice Address - Country:US
Practice Address - Phone:580-824-2291
Practice Address - Fax:580-824-0429
Is Sole Proprietor?:No
Enumeration Date:2005-06-16
Last Update Date:2018-10-17
Deactivation Date:2007-07-17
Deactivation Code:
Reactivation Date:2008-03-18
Provider Licenses
StateLicense IDTaxonomies
KS1500390363AM0700X, 363A00000X
OK2549363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS426724OtherBLUE CROSS/BLUE SHIELD
KS100287510FMedicaid
KS100287510DMedicaid
KS100287510DMedicaid
KS426724OtherBLUE CROSS/BLUE SHIELD