Provider Demographics
NPI:1285061614
Name:ULLAS, REESE A (PA-C)
Entity type:Individual
Prefix:
First Name:REESE
Middle Name:A
Last Name:ULLAS
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:CLARICE
Other - Middle Name:A
Other - Last Name:TWITTY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1211 N 16TH AVE
Mailing Address - Street 2:
Mailing Address - City:YAKIMA
Mailing Address - State:WA
Mailing Address - Zip Code:98902-1347
Mailing Address - Country:US
Mailing Address - Phone:509-454-8888
Mailing Address - Fax:509-453-0061
Practice Address - Street 1:1211 N 16TH AVE
Practice Address - Street 2:
Practice Address - City:YAKIMA
Practice Address - State:WA
Practice Address - Zip Code:98902-1347
Practice Address - Country:US
Practice Address - Phone:509-454-8888
Practice Address - Fax:509-453-0061
Is Sole Proprietor?:No
Enumeration Date:2013-09-30
Last Update Date:2019-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA60418621363A00000X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2011328Medicaid