Provider Demographics
NPI:1720288434
Name:REYES, CECIL S (PA-C)
Entity Type:Individual
Prefix:
First Name:CECIL
Middle Name:S
Last Name:REYES
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 1:22 CORPORATE PLAZA DR
Mailing Address - Street 2:
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92660-7985
Mailing Address - Country:US
Mailing Address - Phone:949-722-7038
Mailing Address - Fax:949-630-4900
Practice Address - Street 1:22 CORPORATE PLAZA DR
Practice Address - Street 2:
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92660-7985
Practice Address - Country:US
Practice Address - Phone:949-722-7038
Practice Address - Fax:949-630-4900
Is Sole Proprietor?:No
Enumeration Date:2007-07-20
Last Update Date:2013-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA16338363AS0400X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CABP657YOtherPTAN
CAQ15609Medicare UPIN