Provider Demographics
NPI:1396819967
Name:REESE, NANCIE J (PA)
Entity type:Individual
Prefix:
First Name:NANCIE
Middle Name:J
Last Name:REESE
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1200 DRIVING PARK AVE
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:NY
Mailing Address - Zip Code:14513-1090
Mailing Address - Country:US
Mailing Address - Phone:315-359-2123
Mailing Address - Fax:315-359-2167
Practice Address - Street 1:1200 DRIVING PARK AVE
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:NY
Practice Address - Zip Code:14513-1090
Practice Address - Country:US
Practice Address - Phone:315-359-2123
Practice Address - Fax:315-359-2167
Is Sole Proprietor?:No
Enumeration Date:2006-11-17
Last Update Date:2014-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY005874-1363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03007063/NWKMedicaid
NY03587831Medicaid
NY03007063/NWKMedicaid
NY03587831Medicaid