Healthcare Provider Details

I. General information

NPI: 1518004308
Provider Name (Legal Business Name): TONY REID P.A.-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/31/2007
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

255 W BULLARD AVE STE 109
CLOVIS CA
93612-0861
US

IV. Provider business mailing address

255 W BULLARD AVE STE 109
CLOVIS CA
93612-0861
US

V. Phone/Fax

Practice location:
  • Phone: 559-297-7563
  • Fax: 559-297-5374
Mailing address:
  • Phone: 559-297-7563
  • Fax: 559-297-5374

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number1034105
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: