Provider Demographics
NPI:1740205871
Name:REYNOLDS, GREGORY (CRNA)
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:
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:PO BOX 456
Mailing Address - Street 2:
Mailing Address - City:ALBERS
Mailing Address - State:IL
Mailing Address - Zip Code:62215-0456
Mailing Address - Country:US
Mailing Address - Phone:618-248-5040
Mailing Address - Fax:
Practice Address - Street 1:9515 HOLY CROSS LN
Practice Address - Street 2:
Practice Address - City:BREESE
Practice Address - State:IL
Practice Address - Zip Code:62230-3618
Practice Address - Country:US
Practice Address - Phone:618-526-4511
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2022-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL41356803367500000X
MO074946367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered