Provider Demographics
NPI:1134657653
Name:REYES, SALLIE (PA)
Entity Type:Individual
Prefix:
First Name:SALLIE
Middle Name:
Last Name:REYES
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3020 CHILDRENS WAY # MC5003
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92123-4223
Mailing Address - Country:US
Mailing Address - Phone:858-300-9630
Mailing Address - Fax:
Practice Address - Street 1:3030 CHILDRENS WAY STE 112
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92123-4226
Practice Address - Country:US
Practice Address - Phone:858-309-7701
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-05-28
Last Update Date:2019-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA54464363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant