Basic Information
| Provider Information | |||||||||
| NPI: | 1902832652 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MCREYNOLDS | ||||||||
| FirstName: | SAMUEL | ||||||||
| MiddleName: | D. | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2825 E BARNETT RD | ||||||||
| Address2: | |||||||||
| City: | MEDFORD | ||||||||
| State: | OR | ||||||||
| PostalCode: | 975048332 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5417894281 | ||||||||
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| Practice Location | |||||||||
| Address1: | 537 UNION AVE | ||||||||
| Address2: | |||||||||
| City: | GRANTS PASS | ||||||||
| State: | OR | ||||||||
| PostalCode: | 975275543 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5414796777 | ||||||||
| FaxNumber: | 5414796779 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/24/2006 | ||||||||
| LastUpdateDate: | 02/18/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/18/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AS0400X | PA60914100 | WA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical |
ID Information
| ID | Type | State | Issuer | Description | 881062 | 05 | AZ | MEDICAID |