Basic Information
| Provider Information | |||||||||
| NPI: | 1053610568 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | REA | ||||||||
| FirstName: | ASHLEY | ||||||||
| MiddleName: | ANN | ||||||||
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| Credential: | P.A. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1809 E 13TH ST STE 402 | ||||||||
| Address2: | |||||||||
| City: | TULSA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 741044431 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9185792300 | ||||||||
| FaxNumber: | 9185792309 | ||||||||
| Practice Location | |||||||||
| Address1: | 1245 S UTICA AVE FL 2 | ||||||||
| Address2: | |||||||||
| City: | TULSA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 74104 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9185792300 | ||||||||
| FaxNumber: | 9185792309 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/23/2011 | ||||||||
| LastUpdateDate: | 05/02/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 05/02/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 2002 | OK | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 200327040A | 05 | OK | MEDICAID |