Provider Demographics
NPI:1760463483
Name:REYNOLDS, ROBERT (PA)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:
Last Name:REYNOLDS
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 TITUS PL
Mailing Address - Street 2:
Mailing Address - City:WALTON
Mailing Address - State:NY
Mailing Address - Zip Code:13856-1457
Mailing Address - Country:US
Mailing Address - Phone:607-865-2100
Mailing Address - Fax:607-785-2584
Practice Address - Street 1:1 TITUS PL
Practice Address - Street 2:
Practice Address - City:WALTON
Practice Address - State:NY
Practice Address - Zip Code:13856-1457
Practice Address - Country:US
Practice Address - Phone:607-865-2100
Practice Address - Fax:607-785-2584
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-09
Last Update Date:2016-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY008363363AM0700X, 207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYJ400005668Medicare PIN
P46018Medicare UPIN
NYCC9862Medicare ID - Type Unspecified