Provider Demographics
NPI:1619311974
Name:GILLINS, REGGIE MICHAEL
Entity Type:Individual
Prefix:
First Name:REGGIE
Middle Name:MICHAEL
Last Name:GILLINS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1478 S MCALLISTER DR
Mailing Address - Street 2:
Mailing Address - City:KANAB
Mailing Address - State:UT
Mailing Address - Zip Code:84741-6113
Mailing Address - Country:US
Mailing Address - Phone:435-708-1269
Mailing Address - Fax:
Practice Address - Street 1:355 N MAIN ST
Practice Address - Street 2:
Practice Address - City:KANAB
Practice Address - State:UT
Practice Address - Zip Code:84741-3260
Practice Address - Country:US
Practice Address - Phone:435-644-4100
Practice Address - Fax:435-644-3366
Is Sole Proprietor?:No
Enumeration Date:2013-04-17
Last Update Date:2023-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZTAP4963363LF0000X
UT7013719-4405363LF0000X
NDR42548363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ809756Medicaid