Provider Demographics
NPI:1043080138
Name:REYNOSO, EMILY MEGAN
Entity Type:Individual
Prefix:
First Name:EMILY
Middle Name:MEGAN
Last Name:REYNOSO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:EMILY
Other - Middle Name:MEGAN
Other - Last Name:ALEXANDER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:CRNA
Mailing Address - Street 1:1724 ROCK VIEW CT
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76112-3712
Mailing Address - Country:US
Mailing Address - Phone:254-652-8411
Mailing Address - Fax:
Practice Address - Street 1:1400 8TH AVE
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-4110
Practice Address - Country:US
Practice Address - Phone:817-926-2544
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-08
Last Update Date:2024-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX147543207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology