Provider Demographics
NPI:1740397413
Name:REYES, ERICSON P
Entity Type:Individual
Prefix:
First Name:ERICSON
Middle Name:P
Last Name:REYES
Suffix:
Gender:M
Credentials:
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 879
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:90714-0879
Mailing Address - Country:US
Mailing Address - Phone:562-630-3111
Mailing Address - Fax:562-630-3107
Practice Address - Street 1:3300 E SOUTH ST STE 308
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:CA
Practice Address - Zip Code:90805-4598
Practice Address - Country:US
Practice Address - Phone:562-630-3111
Practice Address - Fax:562-630-3107
Is Sole Proprietor?:No
Enumeration Date:2006-08-25
Last Update Date:2023-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CANP15834363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
CANP15834OtherNURSE PRACTITIONER LICENS
CA515085OtherRN LICENSE