Provider Demographics
NPI:1801934955
Name:REYNOLDS, RICHARD DAVID (PA-C)
Entity type:Individual
Prefix:
First Name:RICHARD
Middle Name:DAVID
Last Name:REYNOLDS
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 1:333 E CINNAMON DR
Mailing Address - Street 2:APT.#135
Mailing Address - City:LEMOORE
Mailing Address - State:CA
Mailing Address - Zip Code:93245-2885
Mailing Address - Country:US
Mailing Address - Phone:559-925-1591
Mailing Address - Fax:
Practice Address - Street 1:16928 11TH STREET
Practice Address - Street 2:
Practice Address - City:HURON
Practice Address - State:CA
Practice Address - Zip Code:93234
Practice Address - Country:US
Practice Address - Phone:559-945-2541
Practice Address - Fax:559-945-1107
Is Sole Proprietor?:No
Enumeration Date:2007-02-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA19020363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant