Provider Demographics
NPI:1023261369
Name:REYNOSO, WENDY (PA-C)
Entity type:Individual
Prefix:MRS
First Name:WENDY
Middle Name:
Last Name:REYNOSO
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 1:4802 10TH AVE
Mailing Address - Street 2:4TH FLOOR ROOM G
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11219-2916
Mailing Address - Country:US
Mailing Address - Phone:917-523-5658
Mailing Address - Fax:
Practice Address - Street 1:4802 10TH AVE
Practice Address - Street 2:4TH FLOOR ROOM G
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11219-2916
Practice Address - Country:US
Practice Address - Phone:917-523-5658
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-10-30
Last Update Date:2008-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY007951363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical