Provider Demographics
NPI:1891738324
Name:REYES, EDGAR (PA)
Entity Type:Individual
Prefix:MR
First Name:EDGAR
Middle Name:
Last Name:REYES
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 1:7934 SEVILLE AVE
Mailing Address - Street 2:
Mailing Address - City:WALNUT PARK
Mailing Address - State:CA
Mailing Address - Zip Code:90255-6804
Mailing Address - Country:US
Mailing Address - Phone:323-584-9644
Mailing Address - Fax:323-583-0012
Practice Address - Street 1:7934 SEVILLE AVE
Practice Address - Street 2:
Practice Address - City:WALNUT PARK
Practice Address - State:CA
Practice Address - Zip Code:90255-6804
Practice Address - Country:US
Practice Address - Phone:323-584-9644
Practice Address - Fax:323-583-0012
Is Sole Proprietor?:No
Enumeration Date:2006-06-13
Last Update Date:2014-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA17375363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAWPA17375BMedicare ID - Type UnspecifiedPPIN
CAQ42811Medicare UPIN