Basic Information
| Provider Information | |||||||||
| NPI: | 1821259763 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CUELLAR | ||||||||
| FirstName: | REYNA | ||||||||
| MiddleName: | LYNN | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | FUENTES | ||||||||
| OtherFirstName: | REYNA | ||||||||
| OtherMiddleName: | LYNN | ||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | M.D. | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 6301 S MCCLINTOCK DR STE 101 | ||||||||
| Address2: | |||||||||
| City: | TEMPE | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852833393 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4802142300 | ||||||||
| FaxNumber: | 4802142301 | ||||||||
| Practice Location | |||||||||
| Address1: | 3592 S ATHERTON BLVD | ||||||||
| Address2: | #101 | ||||||||
| City: | GILBERT | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852977443 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4802142170 | ||||||||
| FaxNumber: | 4802142171 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/23/2008 | ||||||||
| LastUpdateDate: | 10/03/2012 | ||||||||
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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 | 208000000X | 40187 | AZ | Y | Allopathic & Osteopathic Physicians | Pediatrics |
No ID Information.