Basic Information
Provider Information | |||||||||
NPI: | 1316042732 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | REICHERT | ||||||||
FirstName: | PAUL | ||||||||
MiddleName: | B | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | CRNA | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1191 W 1670 N | ||||||||
Address2: |   | ||||||||
City: | PLEASANT GROVE | ||||||||
State: | UT | ||||||||
PostalCode: | 840629228 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8017965977 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 750 W 800 N | ||||||||
Address2: |   | ||||||||
City: | OREM | ||||||||
State: | UT | ||||||||
PostalCode: | 840573660 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8007484868 | ||||||||
FaxNumber: | 8017335618 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/13/2006 | ||||||||
LastUpdateDate: | 07/08/2007 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | 198716-4406 | UT | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |   |
ID Information
ID | Type | State | Issuer | Description | 7771 | 01 | UT | HEALTHY U | OTHER | TPRA07641 | 01 | UT | MOLINA | OTHER | 47396 | 01 | UT | PEHP | OTHER | 870525882RE1 | 01 | UT | EDUCATORS MUTUAL | OTHER | 107008060102 | 01 | UT | IHC | OTHER | 343291 | 01 | UT | DESERET MUTUAL | OTHER | QM0000076595 | 01 | UT | ALTIUS | OTHER |