Provider Demographics
NPI:1740961788
Name:JIMENEZ, REILLY (PA)
Entity type:Individual
Prefix:
First Name:REILLY
Middle Name:
Last Name:JIMENEZ
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2235 12TH ST APT B117
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83404-5721
Mailing Address - Country:US
Mailing Address - Phone:208-419-1319
Mailing Address - Fax:
Practice Address - Street 1:2235 12TH ST APT B117
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-5721
Practice Address - Country:US
Practice Address - Phone:208-419-1319
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-31
Last Update Date:2025-08-05
Deactivation Date:
Deactivation Code:
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Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant