Provider Demographics
NPI:1023369030
Name:DUTTON, RYAN (PA-C)
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:
Last Name:DUTTON
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:PO BOX 2120
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97208-2120
Mailing Address - Country:US
Mailing Address - Phone:541-274-3278
Mailing Address - Fax:541-274-3275
Practice Address - Street 1:3001 DAGGETT AVE STE 101
Practice Address - Street 2:
Practice Address - City:KLAMATH FALLS
Practice Address - State:OR
Practice Address - Zip Code:97601-1126
Practice Address - Country:US
Practice Address - Phone:541-274-3278
Practice Address - Fax:541-274-3275
Is Sole Proprietor?:No
Enumeration Date:2012-10-01
Last Update Date:2022-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ5236363A00000X
ORPA170495363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ753034Medicaid
AZ753034Medicaid