Provider Demographics
NPI:1891779468
Name:REYNALDO, JENNIFER BUTLER (PA-C)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:BUTLER
Last Name:REYNALDO
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:J
Other - Last Name:BUTLER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1120 FIRST COLONIAL RD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23454-2418
Mailing Address - Country:US
Mailing Address - Phone:757-481-2333
Mailing Address - Fax:757-481-1037
Practice Address - Street 1:1120 FIRST COLONIAL RD
Practice Address - Street 2:SUITE 100
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23454-2418
Practice Address - Country:US
Practice Address - Phone:757-481-2333
Practice Address - Fax:757-481-1037
Is Sole Proprietor?:No
Enumeration Date:2005-12-06
Last Update Date:2015-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCPA030295363AS0400X
NJ25MP00171700363A00000X
VA0110001711363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
Q10154Medicare UPIN