Basic Information
| Provider Information | |||||||||
| NPI: | 1306877808 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | REEVES | ||||||||
| FirstName: | TINA | ||||||||
| MiddleName: | R | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4301 DONIPHAN DR | ||||||||
| Address2: | |||||||||
| City: | NEOSHO | ||||||||
| State: | MO | ||||||||
| PostalCode: | 648509120 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4174519450 | ||||||||
| FaxNumber: | 4174518903 | ||||||||
| Practice Location | |||||||||
| Address1: | 530 S MAIDEN LN | ||||||||
| Address2: | |||||||||
| City: | JOPLIN | ||||||||
| State: | MO | ||||||||
| PostalCode: | 648013084 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4177826200 | ||||||||
| FaxNumber: | 4177826210 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/05/2006 | ||||||||
| LastUpdateDate: | 03/06/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 148710 | MO | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 194619 | 01 | MO | ANTHEM | OTHER | 200267590A | 05 | KS | MEDICAID | 429002702 | 05 | MO | MEDICAID | P00146240 | 01 | RR MEDICARE | OTHER | 200036220A | 05 | OK | MEDICAID |