Provider Demographics
NPI:1326109125
Name:REILLY, DAVID TRAVIS (PA)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:TRAVIS
Last Name:REILLY
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4910 E CLINTON WAY
Mailing Address - Street 2:SUITE 101
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93727-1560
Mailing Address - Country:US
Mailing Address - Phone:559-453-5200
Mailing Address - Fax:559-443-2681
Practice Address - Street 1:255 N. HOWARD
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93701-2214
Practice Address - Country:US
Practice Address - Phone:559-459-7300
Practice Address - Fax:559-459-3750
Is Sole Proprietor?:No
Enumeration Date:2006-12-13
Last Update Date:2010-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA16367363A00000X, 363AS0400X
CAPA 16367363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical