Provider Demographics
NPI:1528336146
Name:ELLIS, RYAN MICHAEL (PA)
Entity type:Individual
Prefix:MR
First Name:RYAN
Middle Name:MICHAEL
Last Name:ELLIS
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 1:36485 INLAND VALLEY DR
Mailing Address - Street 2:
Mailing Address - City:WILDOMAR
Mailing Address - State:CA
Mailing Address - Zip Code:92595-9681
Mailing Address - Country:US
Mailing Address - Phone:951-566-5610
Mailing Address - Fax:
Practice Address - Street 1:36485 INLAND VALLEY DR
Practice Address - Street 2:
Practice Address - City:WILDOMAR
Practice Address - State:CA
Practice Address - Zip Code:92595-9681
Practice Address - Country:US
Practice Address - Phone:951-566-5610
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-12-09
Last Update Date:2021-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA21959363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical