Provider Demographics
NPI:1902958697
Name:REYNOLDS, ELENA TERECE (PA-C)
Entity type:Individual
Prefix:
First Name:ELENA
Middle Name:TERECE
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 1:2149 VALLEYGATE DR STE 101
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28304-3666
Mailing Address - Country:US
Mailing Address - Phone:910-670-0207
Mailing Address - Fax:
Practice Address - Street 1:2053 VALLEYGATE DR
Practice Address - Street 2:SUITE 101
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28304-3747
Practice Address - Country:US
Practice Address - Phone:910-323-9222
Practice Address - Fax:910-223-9783
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-16
Last Update Date:2023-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-00804363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCNCM761AMedicare PIN