Basic Information
| Provider Information | |||||||||
| NPI: | 1508268491 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | REICH | ||||||||
| FirstName: | CHELSEA | ||||||||
| MiddleName: | A | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | PA-C | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | VAN DYKE | ||||||||
| OtherFirstName: | CHELSEA | ||||||||
| OtherMiddleName: | A | ||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | PA-C | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 400 E THIRD STREET | ||||||||
| Address2: | |||||||||
| City: | DU | ||||||||
| State: | MN | ||||||||
| PostalCode: | 558051951 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2188287548 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 720 MAIN AVE | ||||||||
| Address2: | |||||||||
| City: | MOORHEAD | ||||||||
| State: | MN | ||||||||
| PostalCode: | 56560 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2183590399 | ||||||||
| FaxNumber: | 2183590096 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/23/2014 | ||||||||
| LastUpdateDate: | 02/13/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 1012 | SD | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363A00000X | SD | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363A00000X | 12887 | MN | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.