Healthcare Provider Details

I. General information

NPI: 1497283402
Provider Name (Legal Business Name): ROBERT DAVID REYNOLDS JR. APRN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/03/2017
Last Update Date: 12/21/2022
Certification Date: 12/21/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 MEDICAL PARK BLVD STE 255W
BRISTOL TN
37620-7430
US

IV. Provider business mailing address

509 MED TECH PKWY STE 100
JOHNSON CITY TN
37604-2579
US

V. Phone/Fax

Practice location:
  • Phone: 423-844-5560
  • Fax:
Mailing address:
  • Phone: 423-302-6567
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number22665
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: