Healthcare Provider Details

I. General information

NPI: 1801879838
Provider Name (Legal Business Name): MICHAEL J REYES PA C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/23/2005
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

817 E 6TH ST
TISHOMINGO OK
73460-1800
US

IV. Provider business mailing address

1334 N LANSING AVE
TULSA OK
74106-5907
US

V. Phone/Fax

Practice location:
  • Phone: 580-371-2392
  • Fax:
Mailing address:
  • Phone: 918-273-9911
  • Fax: 918-273-9946

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number1474
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: