Provider Demographics
NPI:1578171260
Name:REYNOLDS, MATHEW MAZO
Entity type:Individual
Prefix:
First Name:MATHEW
Middle Name:MAZO
Last Name:REYNOLDS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10039 VINE ST
Mailing Address - Street 2:
Mailing Address - City:LAKESIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92040-3120
Mailing Address - Country:US
Mailing Address - Phone:833-867-4642
Mailing Address - Fax:
Practice Address - Street 1:10039 VINE ST
Practice Address - Street 2:
Practice Address - City:LAKESIDE
Practice Address - State:CA
Practice Address - Zip Code:92040-3120
Practice Address - Country:US
Practice Address - Phone:833-867-4642
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-19
Last Update Date:2025-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-10323363A00000X
CA61945363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant