Provider Demographics
NPI:1124088851
Name:REYNOLDS, LEAH R (PA-C)
Entity type:Individual
Prefix:
First Name:LEAH
Middle Name:R
Last Name:REYNOLDS
Suffix:
Gender:F
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 1:4245 JOHNS CREEK PKWY
Mailing Address - Street 2:STE D
Mailing Address - City:SUWANEE
Mailing Address - State:GA
Mailing Address - Zip Code:30024-9121
Mailing Address - Country:US
Mailing Address - Phone:770-495-3820
Mailing Address - Fax:770-495-3825
Practice Address - Street 1:4245 JOHNS CREEK PKWY
Practice Address - Street 2:STE D
Practice Address - City:SUWANEE
Practice Address - State:GA
Practice Address - Zip Code:30024-9121
Practice Address - Country:US
Practice Address - Phone:770-495-3820
Practice Address - Fax:770-495-3825
Is Sole Proprietor?:No
Enumeration Date:2006-03-25
Last Update Date:2017-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ3344363AS0400X
GA6370363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003121895DMedicaid
GA003121895FMedicaid
AZP00380758OtherRAILROAD MEDICARE
AZ069627Medicaid
AZZ109000Medicare PIN
AZP00380758OtherRAILROAD MEDICARE
GA202I973924Medicare PIN