Provider Demographics
NPI:1043624372
Name:VAZALES, RYAN (DPM)
Entity Type:Individual
Prefix:DR
First Name:RYAN
Middle Name:
Last Name:VAZALES
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5231 HICKORY PARK DR STE D
Mailing Address - Street 2:
Mailing Address - City:GLEN ALLEN
Mailing Address - State:VA
Mailing Address - Zip Code:23059-2619
Mailing Address - Country:US
Mailing Address - Phone:804-390-9878
Mailing Address - Fax:804-404-9855
Practice Address - Street 1:5231 HICKORY PARK DR STE D
Practice Address - Street 2:
Practice Address - City:GLEN ALLEN
Practice Address - State:VA
Practice Address - Zip Code:23059-2619
Practice Address - Country:US
Practice Address - Phone:804-390-9878
Practice Address - Fax:804-404-9855
Is Sole Proprietor?:No
Enumeration Date:2014-06-14
Last Update Date:2021-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0103301197213ES0103X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program