Provider Demographics
NPI:1306800644
Name:REYES, REYNALDO L JR (PHYSICIAN ASSISTANT)
Entity type:Individual
Prefix:
First Name:REYNALDO
Middle Name:L
Last Name:REYES
Suffix:JR
Gender:M
Credentials:PHYSICIAN ASSISTANT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12497 CONQUISTADOR WAY
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92128-2152
Mailing Address - Country:US
Mailing Address - Phone:858-603-3106
Mailing Address - Fax:
Practice Address - Street 1:35000 GUADALCANAL ST
Practice Address - Street 2:BRANCH MEDICAL CLINIC MARINE CORPS RECRUIT DEPOT
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92140
Practice Address - Country:US
Practice Address - Phone:619-532-4056
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-13
Last Update Date:2022-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA58601363AM0700X
1710I1002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical