Provider Demographics
NPI:1699951905
Name:REYNOLDS, TRAY H (PTA)
Entity type:Individual
Prefix:
First Name:TRAY
Middle Name:H
Last Name:REYNOLDS
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:308 WELLINGTON LN
Mailing Address - Street 2:
Mailing Address - City:MOORE
Mailing Address - State:OK
Mailing Address - Zip Code:73160-8104
Mailing Address - Country:US
Mailing Address - Phone:405-799-5840
Mailing Address - Fax:
Practice Address - Street 1:921 NE 13TH ST
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73104-5007
Practice Address - Country:US
Practice Address - Phone:405-270-0501
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-16
Last Update Date:2008-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1572282N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282N00000XHospitalsGeneral Acute Care Hospital