Provider Demographics
NPI:1699851717
Name:REYNOLDS, WESLEY A (CRNA)
Entity Type:Individual
Prefix:
First Name:WESLEY
Middle Name:A
Last Name:REYNOLDS
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4580 PINTAIL CT
Mailing Address - Street 2:
Mailing Address - City:MARTINEZ
Mailing Address - State:GA
Mailing Address - Zip Code:30907-8872
Mailing Address - Country:US
Mailing Address - Phone:706-210-9880
Mailing Address - Fax:
Practice Address - Street 1:4580 PINTAIL CT
Practice Address - Street 2:
Practice Address - City:MARTINEZ
Practice Address - State:GA
Practice Address - Zip Code:30907-8872
Practice Address - Country:US
Practice Address - Phone:706-210-9880
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-31
Last Update Date:2008-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN166976 CRNA367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered