Provider Demographics
NPI:1306034616
Name:REYNOLDS, KERRY R (PA-C)
Entity Type:Individual
Prefix:
First Name:KERRY
Middle Name:R
Last Name:REYNOLDS
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 5546
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80217-5546
Mailing Address - Country:US
Mailing Address - Phone:801-475-3300
Mailing Address - Fax:801-475-3301
Practice Address - Street 1:698 12TH ST
Practice Address - Street 2:
Practice Address - City:OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84404-6200
Practice Address - Country:US
Practice Address - Phone:801-475-3700
Practice Address - Fax:801-475-3701
Is Sole Proprietor?:No
Enumeration Date:2007-10-11
Last Update Date:2021-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT363A00000X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTU000079176Medicare PIN
ID000010164228OtherBLUE SHIELD-DOWNEY
ID16650862Medicare PIN
ID16650865Medicare PIN
ID000010164234OtherBLUE SHIELD-POCATELLO
IDPAH34OtherBLUE CROSS-POCATELLO
ID000010164229OtherBLUE SHIELD-LAVA
IDPAH35OtherBLUE CROSS-MCCAMMON
ID807909500Medicaid
ID16650864Medicare PIN
ID000010164232OtherBLUE SHIELD-AM FALLS
ID000010164233OtherBLUE SHIELD-MCCAMMON
IDPAH31OtherBLUE CROSS-AM FALLS
IDPAH32OtherBLUE CROSS-LAVA
ID1665086Medicare PIN
ID16650861Medicare PIN
ID000010164231OtherBLUE SHIELD-ABERDEEN
IDP00464213OtherRR MEDICARE
IDPAH33OtherBLUE CROSS-ABERDEEN
IDPAH41OtherBLUE CROSS-DOWNEY