Provider Demographics
NPI:1447655063
Name:REYNOLDS, HEATHER (PA-C)
Entity type:Individual
Prefix:
First Name:HEATHER
Middle Name:
Last Name:REYNOLDS
Suffix:
Gender:F
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 1:22 W 23RD ST FL 5
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10010-5240
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3705 N 6100 W
Practice Address - Street 2:
Practice Address - City:IVINS
Practice Address - State:UT
Practice Address - Zip Code:84738
Practice Address - Country:US
Practice Address - Phone:435-688-8198
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-24
Last Update Date:2020-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT352929-1206363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical