Basic Information
| Provider Information | |||||||||
| NPI: | 1629115670 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | REED | ||||||||
| FirstName: | DENNIS | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1008 N MAIN ST | ||||||||
| Address2: | |||||||||
| City: | SIKESTON | ||||||||
| State: | MO | ||||||||
| PostalCode: | 638015044 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5734727406 | ||||||||
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| Practice Location | |||||||||
| Address1: | 314 E MAIN ST | ||||||||
| Address2: | |||||||||
| City: | PORTAGEVILLE | ||||||||
| State: | MO | ||||||||
| PostalCode: | 638731616 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5733793777 | ||||||||
| FaxNumber: | 5733799331 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/31/2007 | ||||||||
| LastUpdateDate: | 03/17/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | DA 105031 | MO | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 105031 | 01 | MO | PHYSICIANS ASSISTANT LICENSE | OTHER |