Provider Demographics
NPI:1124387568
Name:REYNOLDS, TONY L (NP-C)
Entity type:Individual
Prefix:MR
First Name:TONY
Middle Name:L
Last Name:REYNOLDS
Suffix:
Gender:M
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:535 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:ALTURAS
Mailing Address - State:CA
Mailing Address - Zip Code:96101-4114
Mailing Address - Country:US
Mailing Address - Phone:530-233-2288
Mailing Address - Fax:
Practice Address - Street 1:535 S MAIN ST
Practice Address - Street 2:
Practice Address - City:ALTURAS
Practice Address - State:CA
Practice Address - Zip Code:96101-4114
Practice Address - Country:US
Practice Address - Phone:530-233-2288
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-05-04
Last Update Date:2016-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1116552363LF0000X
CA95004432363LF0000X
OR201509529NP-PP363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL634650076Medicare PIN