Provider Demographics
NPI:1538317144
Name:REYNOSO, JORGE LUIS (PA)
Entity Type:Individual
Prefix:MR
First Name:JORGE
Middle Name:LUIS
Last Name:REYNOSO
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 1:315 SURF DR
Mailing Address - Street 2:UNIT 226
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10473-2473
Mailing Address - Country:US
Mailing Address - Phone:347-224-3709
Mailing Address - Fax:
Practice Address - Street 1:70 DUBOIS ST
Practice Address - Street 2:
Practice Address - City:NEWBURGH
Practice Address - State:NY
Practice Address - Zip Code:12550-4851
Practice Address - Country:US
Practice Address - Phone:845-458-4700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-08
Last Update Date:2022-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT3348363AS0400X
NY012742363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical