Healthcare Provider Details

I. General information

NPI: 1134157233
Provider Name (Legal Business Name): JOEL WAYNE REYNOLDS PAC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/28/2006
Last Update Date: 01/23/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

61 CHARLES ST
DEADWOOD SD
57732-1303
US

IV. Provider business mailing address

353 FAIRMONT BLVD ATTEN MSS
RAPID CITY SD
57701-7375
US

V. Phone/Fax

Practice location:
  • Phone: 605-722-6101
  • Fax: 605-719-6133
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number0548
License Number StateSD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: