Basic Information
| Provider Information | |||||||||
| NPI: | 1285074054 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | REYNOLDS | ||||||||
| FirstName: | DEREK | ||||||||
| MiddleName: | J | ||||||||
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| Credential: | FNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 908 NIAGARA FALLS BLVD | ||||||||
| Address2: | SUITE 208 | ||||||||
| City: | NORTH TONAWANDA | ||||||||
| State: | NY | ||||||||
| PostalCode: | 141202019 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7166923302 | ||||||||
| FaxNumber: | 7163323525 | ||||||||
| Practice Location | |||||||||
| Address1: | 183 PARK ST | ||||||||
| Address2: | SUITE 7 | ||||||||
| City: | MALONE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 129531238 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5184812801 | ||||||||
| FaxNumber: | 5184812486 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/26/2013 | ||||||||
| LastUpdateDate: | 06/26/2013 | ||||||||
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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 | 363LF0000X | F338090-1 | NY | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.