Provider Demographics
NPI:1962428730
Name:REICHART, ANGELA L (PA)
Entity type:Individual
Prefix:
First Name:ANGELA
Middle Name:L
Last Name:REICHART
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:7701 YORK AVE S STE 300
Mailing Address - Street 2:
Mailing Address - City:EDINA
Mailing Address - State:MN
Mailing Address - Zip Code:55435-5864
Mailing Address - Country:US
Mailing Address - Phone:952-926-6489
Mailing Address - Fax:952-926-6501
Practice Address - Street 1:4621 E SUPERIOR ST
Practice Address - Street 2:
Practice Address - City:DULUTH
Practice Address - State:MN
Practice Address - Zip Code:55804-2338
Practice Address - Country:US
Practice Address - Phone:218-786-3550
Practice Address - Fax:218-525-7487
Is Sole Proprietor?:No
Enumeration Date:2006-07-14
Last Update Date:2019-06-28
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MN9854363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN579180400Medicaid
MN970001805Medicare ID - Type Unspecified
S73962Medicare UPIN