Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 2251H1200X | Hand | 0880 | AZ |
NPI | 1275521502 |
---|---|
Provider Name | Mr. Charles Christopher Reynolds |
First Address | Phoenix, AZ 85008-6462 |
Second Address | Phoenix, AZ 85008-6462 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 11/10/2005 |
Last Update Date | 01/05/2008 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
095994 | (05) | AZ |
P00960 | (02) | |
Z113264 | MEDICARE GROUP (01) | AZ |