Provider Demographics
NPI:1932126919
Name:REESE, JUDITH L (PA)
Entity Type:Individual
Prefix:
First Name:JUDITH
Middle Name:L
Last Name:REESE
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:JUDITH
Other - Middle Name:L
Other - Last Name:TERNES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4656 40TH AVE S
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58104-4397
Mailing Address - Country:US
Mailing Address - Phone:701-234-8860
Mailing Address - Fax:701-234-8924
Practice Address - Street 1:4656 40TH AVE S
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58104-4397
Practice Address - Country:US
Practice Address - Phone:701-234-8860
Practice Address - Fax:701-234-8924
Is Sole Proprietor?:No
Enumeration Date:2006-07-16
Last Update Date:2012-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NDPAC0352207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND71075Medicaid
ND71075Medicaid