Basic Information
| Provider Information | |||||||||
| NPI: | 1730331570 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | REYES | ||||||||
| FirstName: | CHARLENE | ||||||||
| MiddleName: | N | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6333 CENTER DR | ||||||||
| Address2: | BLDG 16 | ||||||||
| City: | NORFOLK | ||||||||
| State: | VA | ||||||||
| PostalCode: | 235024126 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7574575100 | ||||||||
| FaxNumber: | 7572759857 | ||||||||
| Practice Location | |||||||||
| Address1: | 6333 CENTER DR | ||||||||
| Address2: | BLDG 16 | ||||||||
| City: | NORFOLK | ||||||||
| State: | VA | ||||||||
| PostalCode: | 235024126 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7574575100 | ||||||||
| FaxNumber: | 7572759857 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/10/2008 | ||||||||
| LastUpdateDate: | 10/10/2008 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 0110002916 | VA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.