Provider Demographics
NPI:1790732162
Name:REITZNER, MARC LEWIS (PA)
Entity Type:Individual
Prefix:
First Name:MARC
Middle Name:LEWIS
Last Name:REITZNER
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:PO BOX 9007
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65808-9007
Mailing Address - Country:US
Mailing Address - Phone:417-875-3462
Mailing Address - Fax:
Practice Address - Street 1:3800 S NATIONAL AVE
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65807-5209
Practice Address - Country:US
Practice Address - Phone:417-875-3700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-30
Last Update Date:2018-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2006001738363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO220024502Medicaid
MO1790732162Medicaid
MO745150OtherHEALTHLINK
MOQ65387Medicare UPIN
WA0215421OtherDEPARTMENT OF LABOR WA
MOQ65387OtherUSPS
MO2305711OtherUNITED HEALTHCARE
MO000097301Medicare PIN
MO502277007Medicaid
MOP00287708Medicare PIN