Provider Demographics
NPI:1649928342
Name:REASOR, NATHAN SHANE
Entity type:Individual
Prefix:
First Name:NATHAN
Middle Name:SHANE
Last Name:REASOR
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3205 JEFFERSON ST
Mailing Address - Street 2:
Mailing Address - City:PADUCAH
Mailing Address - State:KY
Mailing Address - Zip Code:42001-4327
Mailing Address - Country:US
Mailing Address - Phone:270-339-5181
Mailing Address - Fax:
Practice Address - Street 1:2601 KENTUCKY AVE STE 301
Practice Address - Street 2:
Practice Address - City:PADUCAH
Practice Address - State:KY
Practice Address - Zip Code:42003-3826
Practice Address - Country:US
Practice Address - Phone:270-575-3113
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-13
Last Update Date:2022-07-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3017378363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily