Provider Demographics
NPI:1750921631
Name:REEVAS, BRENT (APRN, CNP)
Entity type:Individual
Prefix:
First Name:BRENT
Middle Name:
Last Name:REEVAS
Suffix:
Gender:M
Credentials:APRN, CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12251 S 80TH AVE
Mailing Address - Street 2:
Mailing Address - City:PALOS HEIGHTS
Mailing Address - State:IL
Mailing Address - Zip Code:60463-1290
Mailing Address - Country:US
Mailing Address - Phone:708-923-4000
Mailing Address - Fax:708-923-5859
Practice Address - Street 1:12251 S 80TH AVE
Practice Address - Street 2:
Practice Address - City:PALOS HEIGHTS
Practice Address - State:IL
Practice Address - Zip Code:60463-1290
Practice Address - Country:US
Practice Address - Phone:708-923-4000
Practice Address - Fax:708-923-5859
Is Sole Proprietor?:No
Enumeration Date:2020-01-08
Last Update Date:2022-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209020352363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner