Provider Demographics
NPI:1740821099
Name:REYNOLDS, ROBERT DALE JR (CRNA)
Entity type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:DALE
Last Name:REYNOLDS
Suffix:JR
Gender:
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:601 S PIONEER WAY STE F
Mailing Address - Street 2:PMB 372
Mailing Address - City:MOSES LAKE
Mailing Address - State:WA
Mailing Address - Zip Code:98837
Mailing Address - Country:US
Mailing Address - Phone:661-604-5180
Mailing Address - Fax:
Practice Address - Street 1:801 E WHEELER RD
Practice Address - Street 2:
Practice Address - City:MOSES LAKE
Practice Address - State:WA
Practice Address - Zip Code:98837-1820
Practice Address - Country:US
Practice Address - Phone:509-765-5606
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-07
Last Update Date:2025-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT7122459-3102163WC0200X
TXAP143400367500000X
CANA95001216367500000X
WAAP61565233367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163WC0200XNursing Service ProvidersRegistered NurseCritical Care Medicine