Provider Demographics
NPI:1760623532
Name:REYNA, LETICIA S (MT)
Entity Type:Individual
Prefix:
First Name:LETICIA
Middle Name:S
Last Name:REYNA
Suffix:
Gender:F
Credentials:MT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4900 ALAMEDA AVE
Mailing Address - Street 2:SUITE E
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79905-2802
Mailing Address - Country:US
Mailing Address - Phone:915-772-1768
Mailing Address - Fax:915-772-1768
Practice Address - Street 1:4900 ALAMEDA AVE
Practice Address - Street 2:SUITE E
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79905-2802
Practice Address - Country:US
Practice Address - Phone:915-772-1768
Practice Address - Fax:915-772-1768
Is Sole Proprietor?:Yes
Enumeration Date:2009-03-09
Last Update Date:2009-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX45D0509686291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXCL8361Medicare PIN
TXCL8361Medicare UPIN