Provider Demographics
NPI:1457615585
Name:HISADA, REINA (MD)
Entity Type:Individual
Prefix:
First Name:REINA
Middle Name:
Last Name:HISADA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:621 S MAIN ST STE 200
Mailing Address - Street 2:
Mailing Address - City:REIDSVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27320-5034
Mailing Address - Country:US
Mailing Address - Phone:336-349-4454
Mailing Address - Fax:
Practice Address - Street 1:621 S MAIN ST STE 200
Practice Address - Street 2:
Practice Address - City:REIDSVILLE
Practice Address - State:NC
Practice Address - Zip Code:27320-5034
Practice Address - Country:US
Practice Address - Phone:336-349-4454
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-07-03
Last Update Date:2017-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC182996390200000X
NC14576155852084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program