Basic Information
| Provider Information | |||||||||
| NPI: | 1215060835 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | REYNOLDS | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | W. | ||||||||
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| Credential: | RPA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3101 LATROBE DR | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282114849 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7043767362 | ||||||||
| FaxNumber: | 7043761939 | ||||||||
| Practice Location | |||||||||
| Address1: | 3101 LATROBE DR | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282114849 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7043767362 | ||||||||
| FaxNumber: | 7043761939 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/13/2007 | ||||||||
| LastUpdateDate: | 02/19/2009 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | 011759 | NY | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical | 363A00000X | 0010-01036 | NC | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.