Provider Demographics
NPI:1215939772
Name:REYNOLDS, BRYAN JASON (PA C)
Entity type:Individual
Prefix:
First Name:BRYAN
Middle Name:JASON
Last Name:REYNOLDS
Suffix:
Gender:M
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 1:5323 HARRY HINES BLVD
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75390-9087
Mailing Address - Country:US
Mailing Address - Phone:214-645-7000
Mailing Address - Fax:214-645-0078
Practice Address - Street 1:1324 BROWN ST
Practice Address - Street 2:STE 100
Practice Address - City:WAXAHACHIE
Practice Address - State:TX
Practice Address - Zip Code:75165-1421
Practice Address - Country:US
Practice Address - Phone:972-937-8900
Practice Address - Fax:972-937-7936
Is Sole Proprietor?:No
Enumeration Date:2005-08-15
Last Update Date:2022-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA01426363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
8C2409Medicare ID - Type Unspecified
A07469Medicare UPIN