Provider Demographics
NPI:1003814849
Name:NETTLES, RYAN J (PA-C)
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:J
Last Name:NETTLES
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3651 COLLEGE BLVD
Mailing Address - Street 2:#100A
Mailing Address - City:LEAWOOD
Mailing Address - State:KS
Mailing Address - Zip Code:66211-1904
Mailing Address - Country:US
Mailing Address - Phone:913-319-7546
Mailing Address - Fax:913-319-7691
Practice Address - Street 1:3651 COLLEGE BLVD
Practice Address - Street 2:#100A
Practice Address - City:LEAWOOD
Practice Address - State:KS
Practice Address - Zip Code:66211-1904
Practice Address - Country:US
Practice Address - Phone:913-319-7546
Practice Address - Fax:913-319-7691
Is Sole Proprietor?:No
Enumeration Date:2005-07-13
Last Update Date:2011-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS05-25395363A00000X
MO2004027792363A00000X
COPA-2940363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO61037729Medicaid
KS014D451BMedicare ID - Type Unspecified
CO61037729Medicaid