Provider Demographics
NPI:1104798578
Name:REYES, NATHAN RUSSELL
Entity type:Individual
Prefix:
First Name:NATHAN
Middle Name:RUSSELL
Last Name:REYES
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:107 HAYSTACK CT
Mailing Address - Street 2:
Mailing Address - City:BRENTWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:94513-2500
Mailing Address - Country:US
Mailing Address - Phone:408-882-7761
Mailing Address - Fax:
Practice Address - Street 1:550 HARVEST PARK DR STE B
Practice Address - Street 2:
Practice Address - City:BRENTWOOD
Practice Address - State:CA
Practice Address - Zip Code:94513-4058
Practice Address - Country:US
Practice Address - Phone:530-265-9057
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-09-23
Last Update Date:2025-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes373H00000XNursing Service Related ProvidersDay Training/Habilitation Specialist