Provider Demographics
NPI:1932183084
Name:REYELTS, NATHAN (PA-C)
Entity type:Individual
Prefix:
First Name:NATHAN
Middle Name:
Last Name:REYELTS
Suffix:
Gender:M
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 1:1950 CENTER CREEK DR
Mailing Address - Street 2:SUITE 100
Mailing Address - City:FAIRMONT
Mailing Address - State:MN
Mailing Address - Zip Code:56031-3428
Mailing Address - Country:US
Mailing Address - Phone:507-238-4968
Mailing Address - Fax:
Practice Address - Street 1:1950 CENTER CREEK DR
Practice Address - Street 2:SUITE 100
Practice Address - City:FAIRMONT
Practice Address - State:MN
Practice Address - Zip Code:56031-3428
Practice Address - Country:US
Practice Address - Phone:507-238-4968
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-02
Last Update Date:2020-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN9910363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN01-18804OtherMEDICA
MNHP47426OtherHEALTH PARTNERS
MNMH9041041957OtherPREFERRED ONE
MN320K0REMedicaid
MN4686OtherAVERA
IA959478Medicaid
MN2229453OtherARAZ
MN151650700Medicaid
MN320K0REOtherBLUE CROSS
MN131996Medicaid
MNHP47426OtherHEALTH PARTNERS
MN320K0REOtherBLUE CROSS
Q25941Medicare UPIN
MN970002102Medicare NSC