Healthcare Provider Details

I. General information

NPI: 1891738324
Provider Name (Legal Business Name): EDGAR REYES P.A.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/13/2006
Last Update Date: 03/12/2026
Certification Date: 03/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2715 SANTA ANA ST
SOUTH GATE CA
90280-2021
US

IV. Provider business mailing address

2715 SANTA ANA ST
SOUTH GATE CA
90280-2021
US

V. Phone/Fax

Practice location:
  • Phone: 323-583-0450
  • Fax: 323-583-0012
Mailing address:
  • Phone: 323-583-0450
  • Fax: 323-583-0012

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA17375
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: