Provider Demographics
NPI:1417386483
Name:REYNOLDS, JEFFERSON (DNAP, CRNA)
Entity Type:Individual
Prefix:
First Name:JEFFERSON
Middle Name:
Last Name:REYNOLDS
Suffix:
Gender:M
Credentials:DNAP, CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:750 E 34TH ST
Mailing Address - Street 2:
Mailing Address - City:HIBBING
Mailing Address - State:MN
Mailing Address - Zip Code:55746-2341
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:750 E 34TH ST
Practice Address - Street 2:
Practice Address - City:HIBBING
Practice Address - State:MN
Practice Address - Zip Code:55746-2341
Practice Address - Country:US
Practice Address - Phone:218-262-4881
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-11-10
Last Update Date:2018-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024171445367500000X
MNR 229934-3367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered