Provider Demographics
NPI:1306804620
Name:CALLA, RICARDO (PA)
Entity type:Individual
Prefix:
First Name:RICARDO
Middle Name:
Last Name:CALLA
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1995 TECHNOLOGY PKWY
Mailing Address - Street 2:
Mailing Address - City:MECHANICSBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17050-8522
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1995 TECHNOLOGY PKWY
Practice Address - Street 2:
Practice Address - City:MECHANICSBURG
Practice Address - State:PA
Practice Address - Zip Code:17050
Practice Address - Country:US
Practice Address - Phone:717-231-8772
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-03
Last Update Date:2025-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9114542363A00000X
MEPA2746363A00000X
PAMA003389L363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
P75976Medicare UPIN
091069Medicare ID - Type Unspecified