Provider Demographics
NPI:1902832652
Name:MCREYNOLDS, SAMUEL D (PA-C)
Entity Type:Individual
Prefix:MR
First Name:SAMUEL
Middle Name:D
Last Name:MCREYNOLDS
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2825 E BARNETT RD
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97504-8332
Mailing Address - Country:US
Mailing Address - Phone:541-789-4281
Mailing Address - Fax:
Practice Address - Street 1:537 UNION AVE
Practice Address - Street 2:
Practice Address - City:GRANTS PASS
Practice Address - State:OR
Practice Address - Zip Code:97527-5543
Practice Address - Country:US
Practice Address - Phone:541-479-6777
Practice Address - Fax:541-479-6779
Is Sole Proprietor?:No
Enumeration Date:2006-06-24
Last Update Date:2020-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA60914100363AS0400X
AZ1480363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ881062Medicaid
AZ881062Medicaid
AZ100810Medicare ID - Type Unspecified