Provider Demographics
NPI:1972802528
Name:HADLOCK, REECE KIRBY (PA-C)
Entity Type:Individual
Prefix:
First Name:REECE
Middle Name:KIRBY
Last Name:HADLOCK
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 1:606 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:EAGAR
Mailing Address - State:AZ
Mailing Address - Zip Code:85925-9813
Mailing Address - Country:US
Mailing Address - Phone:928-333-5333
Mailing Address - Fax:928-333-5100
Practice Address - Street 1:606 N MAIN ST
Practice Address - Street 2:
Practice Address - City:EAGAR
Practice Address - State:AZ
Practice Address - Zip Code:85925-9813
Practice Address - Country:US
Practice Address - Phone:928-333-5333
Practice Address - Fax:928-333-5100
Is Sole Proprietor?:No
Enumeration Date:2011-03-22
Last Update Date:2012-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ5006363A00000X
NVPA1252363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ657569Medicaid