Provider Demographics
NPI:1679962856
Name:REINECKE, AMBER KATHRYN (PA)
Entity Type:Individual
Prefix:
First Name:AMBER
Middle Name:KATHRYN
Last Name:REINECKE
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:AMBER
Other - Middle Name:KATHRYN
Other - Last Name:MCKNIGHT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:1025 E 2ND ST
Mailing Address - Street 2:
Mailing Address - City:CUSHING
Mailing Address - State:OK
Mailing Address - Zip Code:74023-4136
Mailing Address - Country:US
Mailing Address - Phone:918-225-3627
Mailing Address - Fax:918-225-0871
Practice Address - Street 1:1025 E 2ND ST
Practice Address - Street 2:
Practice Address - City:CUSHING
Practice Address - State:OK
Practice Address - Zip Code:74023-4136
Practice Address - Country:US
Practice Address - Phone:918-225-3627
Practice Address - Fax:918-225-0871
Is Sole Proprietor?:No
Enumeration Date:2015-01-12
Last Update Date:2016-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2478363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200575350AMedicaid
OK392434YLV0Medicare PIN