Healthcare Provider Details

I. General information

NPI: 1023064870
Provider Name (Legal Business Name): REYES TORRES III PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/25/2006
Last Update Date: 11/05/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

55 WHITCHER ST NE SUITE 350
MARIETTA GA
30060-1155
US

IV. Provider business mailing address

3502 VALLEYHAVEN CT
SUWANEE GA
30024-6439
US

V. Phone/Fax

Practice location:
  • Phone: 770-424-6893
  • Fax: 770-424-2024
Mailing address:
  • Phone: 770-424-6893
  • Fax: 770-424-2024

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number003810
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: