Provider Demographics
NPI:1821327602
Name:REYNOLDS, RYLAN (CRNA)
Entity Type:Individual
Prefix:
First Name:RYLAN
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 1:130 COPA DE ORO DR
Mailing Address - Street 2:
Mailing Address - City:BREA
Mailing Address - State:CA
Mailing Address - Zip Code:92823-7013
Mailing Address - Country:US
Mailing Address - Phone:657-275-9145
Mailing Address - Fax:
Practice Address - Street 1:130 COPA DE ORO DR
Practice Address - Street 2:
Practice Address - City:BREA
Practice Address - State:CA
Practice Address - Zip Code:92823-7013
Practice Address - Country:US
Practice Address - Phone:657-275-9145
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-12-08
Last Update Date:2016-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024168626367500000X
CANA95000134367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered