Provider Demographics
NPI:1427056357
Name:REYNOLDS, BRANDEN R (MD)
Entity type:Individual
Prefix:DR
First Name:BRANDEN
Middle Name:R
Last Name:REYNOLDS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:62 W 7TH AVE STE 110
Mailing Address - Street 2:
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99204-2321
Mailing Address - Country:US
Mailing Address - Phone:509-456-0262
Mailing Address - Fax:509-462-5059
Practice Address - Street 1:62 W 7TH AVE STE 110
Practice Address - Street 2:
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99204-2321
Practice Address - Country:US
Practice Address - Phone:509-456-0262
Practice Address - Fax:509-462-5059
Is Sole Proprietor?:No
Enumeration Date:2005-07-13
Last Update Date:2021-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00032781208G00000X
IDM-8942208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAG8878301OtherMEDICARE PTAN
WAG8871050OtherMEDICARE PTAN
ID11106891OtherMEDICARE PTAN
ID805509000Medicaid
WA8195828Medicaid
WAG30297Medicare UPIN
WAGAB10947Medicare PIN
ID805509000Medicaid