Provider Demographics
NPI:1790294759
Name:REINKING, BRYANT WILLIAM (PA)
Entity Type:Individual
Prefix:
First Name:BRYANT
Middle Name:WILLIAM
Last Name:REINKING
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 1:1023 E SAN MIGUEL ST
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80903-2703
Mailing Address - Country:US
Mailing Address - Phone:970-389-6171
Mailing Address - Fax:
Practice Address - Street 1:6011 E WOODMEN RD STE 360
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80923-2606
Practice Address - Country:US
Practice Address - Phone:719-571-8550
Practice Address - Fax:719-571-8555
Is Sole Proprietor?:No
Enumeration Date:2017-09-21
Last Update Date:2017-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
COPA.0005165363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant