Provider Demographics
NPI:1730288564
Name:MCREYNOLDS, JOEL GREG (PA-C)
Entity Type:Individual
Prefix:
First Name:JOEL
Middle Name:GREG
Last Name:MCREYNOLDS
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 1:2810 W 35TH ST
Mailing Address - Street 2:
Mailing Address - City:KEARNEY
Mailing Address - State:NE
Mailing Address - Zip Code:68845-2909
Mailing Address - Country:US
Mailing Address - Phone:308-865-2570
Mailing Address - Fax:308-865-2508
Practice Address - Street 1:2810 W 35TH ST
Practice Address - Street 2:
Practice Address - City:KEARNEY
Practice Address - State:NE
Practice Address - Zip Code:68845-2909
Practice Address - Country:US
Practice Address - Phone:308-865-2570
Practice Address - Fax:308-865-2508
Is Sole Proprietor?:No
Enumeration Date:2006-09-21
Last Update Date:2014-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE971363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS100414240AOtherKANSAS MEDICAID
NE37450OtherBCBS INDIVIDUAL PROVIDER
NE47062901713Medicaid
KS100414240AOtherKANSAS MEDICAID
NE37450OtherBCBS INDIVIDUAL PROVIDER