Provider Demographics
NPI:1710357538
Name:JOSEPH, REENA (AGPNP)
Entity Type:Individual
Prefix:
First Name:REENA
Middle Name:
Last Name:JOSEPH
Suffix:
Gender:F
Credentials:AGPNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4063 CARGILL DR
Mailing Address - Street 2:
Mailing Address - City:ROUND ROCK
Mailing Address - State:TX
Mailing Address - Zip Code:78681-5523
Mailing Address - Country:US
Mailing Address - Phone:630-618-1031
Mailing Address - Fax:
Practice Address - Street 1:4063 CARGILL DR
Practice Address - Street 2:
Practice Address - City:ROUND ROCK
Practice Address - State:TX
Practice Address - Zip Code:78681-5523
Practice Address - Country:US
Practice Address - Phone:630-618-1031
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-10-06
Last Update Date:2016-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP129043363LA2200X, 363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX470909YM8AMedicare PIN