Provider Demographics
NPI:1699751453
Name:REYNOLDS, DELLA SUE (PA-C)
Entity type:Individual
Prefix:MS
First Name:DELLA
Middle Name:SUE
Last Name:REYNOLDS
Suffix:
Gender:F
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 1:16 MEDICAL PARK DR
Mailing Address - Street 2:
Mailing Address - City:ASHEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28803-2493
Mailing Address - Country:US
Mailing Address - Phone:828-274-4880
Mailing Address - Fax:828-274-6868
Practice Address - Street 1:16 MEDICAL PARK DR
Practice Address - Street 2:
Practice Address - City:ASHEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28803-2493
Practice Address - Country:US
Practice Address - Phone:828-274-4880
Practice Address - Fax:828-274-6868
Is Sole Proprietor?:No
Enumeration Date:2005-12-22
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC103052363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCP20742Medicare UPIN
NC2753001CMedicare ID - Type UnspecifiedPROVIDER NUMBER