Provider Demographics
NPI:1629092580
Name:REILLY, ROBERT JAMES (PA-C)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:JAMES
Last Name:REILLY
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2707 L ST
Mailing Address - Street 2:SUITE 1
Mailing Address - City:ORD
Mailing Address - State:NE
Mailing Address - Zip Code:68862-1275
Mailing Address - Country:US
Mailing Address - Phone:308-728-4202
Mailing Address - Fax:308-728-3500
Practice Address - Street 1:2707 L ST
Practice Address - Street 2:SUITE 1
Practice Address - City:ORD
Practice Address - State:NE
Practice Address - Zip Code:68862-1275
Practice Address - Country:US
Practice Address - Phone:308-728-4202
Practice Address - Fax:308-728-3500
Is Sole Proprietor?:No
Enumeration Date:2006-07-26
Last Update Date:2013-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE563363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NER29958Medicare UPIN
NE279713Medicare PIN