Provider Demographics
NPI:1306932470
Name:BOBBY D REYNOLDS II
Entity type:Organization
Organization Name:BOBBY D REYNOLDS II
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:BOBBY
Authorized Official - Middle Name:D
Authorized Official - Last Name:REYNOLDS
Authorized Official - Suffix:II
Authorized Official - Credentials:FNP
Authorized Official - Phone:423-282-4107
Mailing Address - Street 1:3010 BRISTOL HWY
Mailing Address - Street 2:
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37601-1512
Mailing Address - Country:US
Mailing Address - Phone:423-282-4170
Mailing Address - Fax:423-282-4903
Practice Address - Street 1:3010 BRISTOL HWY
Practice Address - Street 2:
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37601-1512
Practice Address - Country:US
Practice Address - Phone:423-282-4170
Practice Address - Fax:423-282-4903
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-05
Last Update Date:2007-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3700419Medicaid
TN3700419Medicare PIN