Healthcare Provider Details

I. General information

NPI: 1104739325
Provider Name (Legal Business Name): REYNALDO ANTONIO JOSE FNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/28/2026
Last Update Date: 09/28/2026
Certification Date: 09/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

410 S. BROADWAYST.
ELSA TX
78543
US

IV. Provider business mailing address

3619 BRIDGET ST
EDINBURG TX
78539-3148
US

V. Phone/Fax

Practice location:
  • Phone: 956-262-9805
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number1231754
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: