Provider Demographics
NPI:1861737439
Name:JOSEPH, REGINALD (PA)
Entity type:Individual
Prefix:
First Name:REGINALD
Middle Name:
Last Name:JOSEPH
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:3300 S FISKE BLVD
Mailing Address - Street 2:
Mailing Address - City:ROCKLEDGE
Mailing Address - State:FL
Mailing Address - Zip Code:32955-4306
Mailing Address - Country:US
Mailing Address - Phone:321-725-4505
Mailing Address - Fax:321-951-7408
Practice Address - Street 1:1223 GATEWAY DR
Practice Address - Street 2:SUITE 1E
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32901
Practice Address - Country:US
Practice Address - Phone:321-725-4505
Practice Address - Fax:321-409-8932
Is Sole Proprietor?:No
Enumeration Date:2012-12-07
Last Update Date:2018-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9106973363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLGW561VOtherMEDICARE
FLPENDINGMedicaid