Provider Demographics
NPI:1043784432
Name:REYNOLDS, ALEX RICHARD (PA-C)
Entity type:Individual
Prefix:MR
First Name:ALEX
Middle Name:RICHARD
Last Name:REYNOLDS
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2147
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33902-2147
Mailing Address - Country:US
Mailing Address - Phone:239-343-3780
Mailing Address - Fax:239-343-3781
Practice Address - Street 1:12700 CREEKSIDE LN STE 301
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33919-3356
Practice Address - Country:US
Practice Address - Phone:239-343-3780
Practice Address - Fax:239-343-3781
Is Sole Proprietor?:No
Enumeration Date:2019-01-18
Last Update Date:2024-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363AS0400X
FLPA9111617363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLPA9111617OtherMEDICAL LICENSE