Provider Demographics
NPI:1518933852
Name:REYNOLDS, JEREMY (PA-C)
Entity Type:Individual
Prefix:MR
First Name:JEREMY
Middle Name:
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 1:322 COLEMAN ST
Mailing Address - Street 2:PO BOX 60
Mailing Address - City:MARLIN
Mailing Address - State:TX
Mailing Address - Zip Code:76661-2358
Mailing Address - Country:US
Mailing Address - Phone:254-803-3561
Mailing Address - Fax:254-883-6066
Practice Address - Street 1:322 COLEMAN ST
Practice Address - Street 2:FALLS COMMUNITY HOSPITAL
Practice Address - City:MARLIN
Practice Address - State:TX
Practice Address - Zip Code:76661-2358
Practice Address - Country:US
Practice Address - Phone:254-803-3561
Practice Address - Fax:254-883-6066
Is Sole Proprietor?:No
Enumeration Date:2006-02-27
Last Update Date:2010-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA06282363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0815318-01Medicaid
NYVAD000Medicare UPIN
TX0815318-01Medicaid