Provider Demographics
NPI:1891097234
Name:REYNOLDS, MERRICK GORDON (PA)
Entity Type:Individual
Prefix:
First Name:MERRICK
Middle Name:GORDON
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 1:526 SHOUP AVE W
Mailing Address - Street 2:SUITE E
Mailing Address - City:TWIN FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83301-5050
Mailing Address - Country:US
Mailing Address - Phone:208-733-1112
Mailing Address - Fax:208-732-1212
Practice Address - Street 1:526 SHOUP AVE W
Practice Address - Street 2:SUITE E
Practice Address - City:TWIN FALLS
Practice Address - State:ID
Practice Address - Zip Code:83301-5050
Practice Address - Country:US
Practice Address - Phone:208-733-1112
Practice Address - Fax:208-732-1212
Is Sole Proprietor?:No
Enumeration Date:2010-11-17
Last Update Date:2010-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPA876363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical