MEDICARE: JANNELLE GWYNETH REYNOLDS PA-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant	PA20862	CA
2	363A00000X	Physician Assistant	15-01382	KS
3	363A00000X	Physician Assistant

General Provider Information

NPI Number	:	1497073811
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JANNELLE GWYNETH REYNOLDS PA-C

Provider Business Mailing Address
First Line	:	2402 UNIVERISTY DR
Second Line	:
City	:	KEARNEY
State	:	NE
Zip	:	68849-2217
Country	:	US
Telephone Number	:	970-214-3570
Fax Number	:

Provider Business Practice Location Address
First Line	:	2510 11TH AVE
Second Line	:
City	:	KEARNEY
State	:	NE
Zip	:	68849-2247
Country	:	US
Telephone Number	:	970-214-3570
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/10/2010
Last Update Date	:	08/06/2019

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