Provider Demographics
NPI:1730214065
Name:PESINA, REYNALDO (PT)
Entity type:Individual
Prefix:MR
First Name:REYNALDO
Middle Name:
Last Name:PESINA
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:72795 S DELLEKER
Mailing Address - Street 2:
Mailing Address - City:PORTOLA
Mailing Address - State:CA
Mailing Address - Zip Code:96122
Mailing Address - Country:US
Mailing Address - Phone:530-832-1701
Mailing Address - Fax:
Practice Address - Street 1:76 CRESENT WAY
Practice Address - Street 2:
Practice Address - City:QUINCY
Practice Address - State:CA
Practice Address - Zip Code:95970
Practice Address - Country:US
Practice Address - Phone:530-283-0314
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT17342174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA0PT173420OtherBLUE SHIELD
CA0PT173420Medicare ID - Type Unspecified