Basic Information
| Provider Information | |||||||||
| NPI: | 1962029637 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | REYES | ||||||||
| FirstName: | RANDY | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7147 CELOME WAY | ||||||||
| Address2: | |||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921294546 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8586037591 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 683 LOMAS SANTA FE DR | ||||||||
| Address2: | |||||||||
| City: | SOLANA BEACH | ||||||||
| State: | CA | ||||||||
| PostalCode: | 920751412 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8587556697 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/29/2020 | ||||||||
| LastUpdateDate: | 09/16/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 09/16/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 95013722 | CA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363L00000X | 95013722 | CA | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
No ID Information.