Provider Demographics
NPI:1104832039
Name:REID, MICHAEL T (CRNA)
Entity type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:T
Last Name:REID
Suffix:
Gender:M
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:PO BOX 1448
Mailing Address - Street 2:
Mailing Address - City:RANCHO CUCAMONGA
Mailing Address - State:CA
Mailing Address - Zip Code:91729-1448
Mailing Address - Country:US
Mailing Address - Phone:909-946-5752
Mailing Address - Fax:909-985-3858
Practice Address - Street 1:900 E WASHINGTON ST
Practice Address - Street 2:STE. 100
Practice Address - City:COLTON
Practice Address - State:CA
Practice Address - Zip Code:92324-7111
Practice Address - Country:US
Practice Address - Phone:909-370-2190
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-31
Last Update Date:2012-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CANA 2132367500000X
CANA2132367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ21638ZMedicare ID - Type Unspecified