Provider Demographics
NPI:1215060835
Name:REYNOLDS, MICHAEL WARREN (RPA)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:WARREN
Last Name:REYNOLDS
Suffix:
Gender:M
Credentials:RPA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3101 LATROBE DR
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28211-4849
Mailing Address - Country:US
Mailing Address - Phone:704-376-7362
Mailing Address - Fax:704-376-1939
Practice Address - Street 1:3101 LATROBE DR
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28211-4849
Practice Address - Country:US
Practice Address - Phone:704-376-7362
Practice Address - Fax:704-376-1939
Is Sole Proprietor?:No
Enumeration Date:2007-03-13
Last Update Date:2024-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY011759363AM0700X
NC0010-01036363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYPENDINGMedicare ID - Type UnspecifiedMECIARE PROVIDER NUM.