Provider Demographics
NPI:1629069422
Name:REYNOLDS, MARK E (FNAP)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:E
Last Name:REYNOLDS
Suffix:
Gender:M
Credentials:FNAP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3712 22ND ST
Mailing Address - Street 2:
Mailing Address - City:LUBBOCK
Mailing Address - State:TX
Mailing Address - Zip Code:79410-1312
Mailing Address - Country:US
Mailing Address - Phone:806-795-5561
Mailing Address - Fax:806-793-9817
Practice Address - Street 1:3712 22ND ST
Practice Address - Street 2:
Practice Address - City:LUBBOCK
Practice Address - State:TX
Practice Address - Zip Code:79410-1312
Practice Address - Country:US
Practice Address - Phone:806-795-5561
Practice Address - Fax:806-793-9817
Is Sole Proprietor?:No
Enumeration Date:2005-10-31
Last Update Date:2008-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX566392363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0074JYOtherBLUE CROSS BLUE SHIELD
TX148066702Medicaid
TX0074JYOtherBLUE CROSS BLUE SHIELD
TXS87577Medicare UPIN