Provider Demographics
NPI:1710911292
Name:REAVES, WAYNE RANSOM
Entity Type:Individual
Prefix:
First Name:WAYNE
Middle Name:RANSOM
Last Name:REAVES
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O. BOX 48174
Mailing Address - Street 2:
Mailing Address - City:ATHENS
Mailing Address - State:GA
Mailing Address - Zip Code:30604
Mailing Address - Country:US
Mailing Address - Phone:706-549-2410
Mailing Address - Fax:706-369-8968
Practice Address - Street 1:2092 PRINCE AVE
Practice Address - Street 2:
Practice Address - City:ATHENS
Practice Address - State:GA
Practice Address - Zip Code:30606-6047
Practice Address - Country:US
Practice Address - Phone:706-549-2410
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-10
Last Update Date:2007-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA52070313OtherBLUE CROSS BLUE SHIELD GA
GA52070313OtherBLUE CROSS BLUE SHIELD GA