Provider Demographics
NPI:1285074054
Name:REYNOLDS, DEREK JOHN (FNP-C)
Entity type:Individual
Prefix:
First Name:DEREK
Middle Name:JOHN
Last Name:REYNOLDS
Suffix:
Gender:M
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:SAINT REGIS MOHAWK TRIBE HEALTH SERVICES
Mailing Address - Street 2:404 STATE ROUTE 37
Mailing Address - City:HOGANSBURG
Mailing Address - State:NY
Mailing Address - Zip Code:13655-3109
Mailing Address - Country:US
Mailing Address - Phone:518-358-3141
Mailing Address - Fax:518-358-9175
Practice Address - Street 1:SAINT REGIS MOHAWK TRIBE HEALTH SERVICES
Practice Address - Street 2:404 STATE ROUTE 37
Practice Address - City:HOGANSBURG
Practice Address - State:NY
Practice Address - Zip Code:13655-3109
Practice Address - Country:US
Practice Address - Phone:518-358-3141
Practice Address - Fax:518-358-9175
Is Sole Proprietor?:No
Enumeration Date:2013-06-26
Last Update Date:2023-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF338090-1363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03619812Medicaid