Provider Demographics
NPI:1215610613
Name:PETRASANTA, RYAN STEPHEN
Entity type:Individual
Prefix:
First Name:RYAN
Middle Name:STEPHEN
Last Name:PETRASANTA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4946 S MONARCH PL
Mailing Address - Street 2:
Mailing Address - City:ONTARIO
Mailing Address - State:CA
Mailing Address - Zip Code:91762-7336
Mailing Address - Country:US
Mailing Address - Phone:626-758-7435
Mailing Address - Fax:
Practice Address - Street 1:4946 S MONARCH PL
Practice Address - Street 2:
Practice Address - City:ONTARIO
Practice Address - State:CA
Practice Address - Zip Code:91762-7336
Practice Address - Country:US
Practice Address - Phone:626-758-7435
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-11
Last Update Date:2023-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95129572163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse