Basic Information
| Provider Information | |||||||||
| NPI: | 1619157385 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | REYNA | ||||||||
| FirstName: | GWENDOLYN | ||||||||
| MiddleName: | G | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5080 SPECTRUM DR | ||||||||
| Address2: | SUITE 1200 WEST | ||||||||
| City: | ADDISON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 750014648 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8002323550 | ||||||||
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| Practice Location | |||||||||
| Address1: | 801 ENCINO PL NE | ||||||||
| Address2: | SUITE E-12 | ||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871022612 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5058425151 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/09/2007 | ||||||||
| LastUpdateDate: | 07/09/2009 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2083X0100X | MD2007-0053 | NM | Y | Allopathic & Osteopathic Physicians | Preventive Medicine | Occupational Medicine |
ID Information
| ID | Type | State | Issuer | Description | 10231773 | 05 | NM | MEDICAID | 53938577 | 05 | NM | MEDICAID | 46650024 | 05 | NM | MEDICAID | 28777841 | 05 | NM | MEDICAID | 51305879 | 05 | NM | MEDICAID | 01786342 | 05 | NM | MEDICAID |