Basic Information
| Provider Information | |||||||||
| NPI: | 1093950297 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | REYNOLDS | ||||||||
| FirstName: | WARREN | ||||||||
| MiddleName: | DOUGLAS | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3100 MACCORKLE SEAVE 900 | ||||||||
| Address2: | |||||||||
| City: | CHARLESTON | ||||||||
| State: | WV | ||||||||
| PostalCode: | 253041223 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3043883580 | ||||||||
| FaxNumber: | 3043883585 | ||||||||
| Practice Location | |||||||||
| Address1: | 415 MORRIS ST | ||||||||
| Address2: | SUITE 201 | ||||||||
| City: | CHARLESTON | ||||||||
| State: | WV | ||||||||
| PostalCode: | 253011842 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3043887700 | ||||||||
| FaxNumber: | 3043887755 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/03/2008 | ||||||||
| LastUpdateDate: | 12/21/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 880 | WV | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363AS0400X | 457 | WV | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical |
No ID Information.