Provider Demographics
NPI:1154365039
Name:REYES, RAPHAEL O (PA)
Entity type:Individual
Prefix:MR
First Name:RAPHAEL
Middle Name:O
Last Name:REYES
Suffix:
Gender:M
Credentials:PA
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Mailing Address - Street 1:697 MAITLAND AVENUE
Mailing Address - Street 2:SUITE 1002
Mailing Address - City:ALTAMONTE SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:32701
Mailing Address - Country:US
Mailing Address - Phone:407-539-2111
Mailing Address - Fax:407-539-1211
Practice Address - Street 1:539 MAITLAND AVENUE
Practice Address - Street 2:SUITE 1002
Practice Address - City:ALTAMONTE SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:32701
Practice Address - Country:US
Practice Address - Phone:407-539-2111
Practice Address - Fax:407-539-1211
Is Sole Proprietor?:No
Enumeration Date:2006-06-15
Last Update Date:2013-08-22
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Provider Licenses
StateLicense IDTaxonomies
FLPA2067363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
P98726Medicare UPIN
FLU1390YMedicare PIN