Provider Demographics
NPI:1801879838
Name:REYES, MICHAEL J (PA C)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:J
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 1:1334 N LANSING AVE
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74106-5907
Mailing Address - Country:US
Mailing Address - Phone:918-273-9911
Mailing Address - Fax:918-273-9946
Practice Address - Street 1:817 E 6TH ST
Practice Address - Street 2:
Practice Address - City:TISHOMINGO
Practice Address - State:OK
Practice Address - Zip Code:73460-1800
Practice Address - Country:US
Practice Address - Phone:580-371-2392
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-23
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1474363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100768880FMedicaid
OK100768880IMedicaid
OK100768880JMedicaid
OK37-1803OtherMEDICARE
OK37-1832OtherMEDICARE
OK37-1834OtherMEDICARE
OK100768880FMedicaid
OK100768880JMedicaid