Provider Demographics
NPI:1699212357
Name:REITER, GREGORY (PA-C)
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:
Last Name:REITER
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 1:1200 18TH ST SW
Mailing Address - Street 2:
Mailing Address - City:CEDAR RAPIDS
Mailing Address - State:IA
Mailing Address - Zip Code:52404-1770
Mailing Address - Country:US
Mailing Address - Phone:319-215-7286
Mailing Address - Fax:
Practice Address - Street 1:1026 A AVE NE
Practice Address - Street 2:
Practice Address - City:CEDAR RAPIDS
Practice Address - State:IA
Practice Address - Zip Code:52402
Practice Address - Country:US
Practice Address - Phone:319-369-7105
Practice Address - Fax:319-369-8335
Is Sole Proprietor?:No
Enumeration Date:2017-01-19
Last Update Date:2018-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA084921363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA084921OtherIOWA MEDICAL LICENSE