Provider Demographics
NPI:1629115670
Name:REED, DENNIS (PA)
Entity Type:Individual
Prefix:MR
First Name:DENNIS
Middle Name:
Last Name:REED
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1008 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:SIKESTON
Mailing Address - State:MO
Mailing Address - Zip Code:63801-5044
Mailing Address - Country:US
Mailing Address - Phone:573-472-7406
Mailing Address - Fax:
Practice Address - Street 1:314 E MAIN ST
Practice Address - Street 2:
Practice Address - City:PORTAGEVILLE
Practice Address - State:MO
Practice Address - Zip Code:63873-1616
Practice Address - Country:US
Practice Address - Phone:573-379-3777
Practice Address - Fax:573-379-9331
Is Sole Proprietor?:No
Enumeration Date:2007-01-31
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MODA 105031363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO105031OtherPHYSICIANS ASSISTANT LICENSE