Provider Demographics
NPI:1366514127
Name:MANSHOLT, RYAN FERREL (PAC)
Entity type:Individual
Prefix:
First Name:RYAN
Middle Name:FERREL
Last Name:MANSHOLT
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2801 PURCELL ST
Mailing Address - Street 2:
Mailing Address - City:BRIGHTON
Mailing Address - State:CO
Mailing Address - Zip Code:80601-3551
Mailing Address - Country:US
Mailing Address - Phone:303-659-3199
Mailing Address - Fax:303-558-8011
Practice Address - Street 1:9351 GRANT ST
Practice Address - Street 2:SUITE 100
Practice Address - City:THORNTON
Practice Address - State:CO
Practice Address - Zip Code:80229-4358
Practice Address - Country:US
Practice Address - Phone:303-280-3893
Practice Address - Fax:303-280-3908
Is Sole Proprietor?:No
Enumeration Date:2006-11-15
Last Update Date:2015-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085002874363A00000X
COPA.0003747363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILK53523Medicare PIN
ILQ73888Medicare UPIN
ILK33844Medicare PIN