Provider Demographics
NPI:1457759300
Name:REYNOLDS, ELLEN (PA-C)
Entity Type:Individual
Prefix:
First Name:ELLEN
Middle Name:
Last Name:REYNOLDS
Suffix:
Gender:F
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 1:120 N C AVE
Mailing Address - Street 2:
Mailing Address - City:THERMOPOLIS
Mailing Address - State:WY
Mailing Address - Zip Code:82443-2410
Mailing Address - Country:US
Mailing Address - Phone:307-864-5534
Mailing Address - Fax:307-864-9470
Practice Address - Street 1:120 N C AVE
Practice Address - Street 2:
Practice Address - City:THERMOPOLIS
Practice Address - State:WY
Practice Address - Zip Code:82443-2410
Practice Address - Country:US
Practice Address - Phone:307-864-5534
Practice Address - Fax:307-864-9470
Is Sole Proprietor?:No
Enumeration Date:2014-12-09
Last Update Date:2014-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WYPT624363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant