Basic Information
| Provider Information | |||||||||
| NPI: | 1821502683 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | REAGAN | ||||||||
| FirstName: | MATTHEW | ||||||||
| MiddleName: | LAURANCE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10139 GLENNON ST | ||||||||
| Address2: | |||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921242914 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6192740158 | ||||||||
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| Practice Location | |||||||||
| Address1: | 480 CENTRAL AVE | ||||||||
| Address2: | |||||||||
| City: | JBPHH | ||||||||
| State: | HI | ||||||||
| PostalCode: | 968604908 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8084731880 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/30/2017 | ||||||||
| LastUpdateDate: | 11/30/2017 | ||||||||
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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 | 1710I1002X | Y | Other Service Providers | Military Health Care Provider | Independent Duty Corpsman |
No ID Information.