Provider Demographics
NPI:1427165836
Name:REEVES, DIANE M (PA-C)
Entity type:Individual
Prefix:MS
First Name:DIANE
Middle Name:M
Last Name:REEVES
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 HEALTH SERVICE DR.
Mailing Address - Street 2:KYLE I.H.S. OUT PATIENT CLINIC
Mailing Address - City:KYLE
Mailing Address - State:SD
Mailing Address - Zip Code:57752
Mailing Address - Country:US
Mailing Address - Phone:605-455-2451
Mailing Address - Fax:605-455-1529
Practice Address - Street 1:1000 HEALTH SERVICE DR.
Practice Address - Street 2:KYLE I.H.S. OUT PATIENT CLINIC
Practice Address - City:KYLE
Practice Address - State:SD
Practice Address - Zip Code:57752
Practice Address - Country:US
Practice Address - Phone:605-455-2451
Practice Address - Fax:605-455-1529
Is Sole Proprietor?:No
Enumeration Date:2006-08-23
Last Update Date:2012-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX41808183500000X
MI5302026024183500000X
TXPA03219363A00000X
MI5601002364363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX138950100OtherFIRST CARE
TX138950100OtherSOUTHWEST LIFE & HEALTH
TX8N7081OtherBCBS
Q15824Medicare UPIN
TX8N7081OtherBCBS