Provider Demographics
NPI:1104930536
Name:REITZ, BRIAN L (PA)
Entity type:Individual
Prefix:
First Name:BRIAN
Middle Name:L
Last Name:REITZ
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 1:6065 NANTUCKET LN
Mailing Address - Street 2:
Mailing Address - City:YORBA LINDA
Mailing Address - State:CA
Mailing Address - Zip Code:92887-4714
Mailing Address - Country:US
Mailing Address - Phone:714-206-8285
Mailing Address - Fax:
Practice Address - Street 1:411 WEST LAKEVIEW AVE
Practice Address - Street 2:
Practice Address - City:ANAHEIM
Practice Address - State:CA
Practice Address - Zip Code:92807
Practice Address - Country:US
Practice Address - Phone:714-279-5527
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-19
Last Update Date:2021-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAQ03353363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAQ03353Medicare UPIN