Basic Information
| Provider Information | |||||||||
| NPI: | 1477620284 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | REYNA | ||||||||
| FirstName: | ROBERT | ||||||||
| MiddleName: | M. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1211 24TH ST | ||||||||
| Address2: | |||||||||
| City: | ANACORTES | ||||||||
| State: | WA | ||||||||
| PostalCode: | 982212562 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3602991300 | ||||||||
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| Practice Location | |||||||||
| Address1: | 5701 W CHARLESTON BLVD STE 105 | ||||||||
| Address2: | |||||||||
| City: | LAS VEGAS | ||||||||
| State: | NV | ||||||||
| PostalCode: | 891461256 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7028779514 | ||||||||
| FaxNumber: | 7023123510 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/29/2006 | ||||||||
| LastUpdateDate: | 10/29/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/29/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207QS1201X | MD6026881 | WA | Y | Allopathic & Osteopathic Physicians | Family Medicine | Sleep Medicine | 207QS1201X | 13011 | NV | N | Allopathic & Osteopathic Physicians | Family Medicine | Sleep Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1477620284 | 05 | NV | MEDICAID |