Provider Demographics
NPI:1043763253
Name:AGOSTINELLI, RYAN DAVID (PA)
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:DAVID
Last Name:AGOSTINELLI
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 1:9001 N COUNTRY HOMES BLVD
Mailing Address - Street 2:
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99218-2072
Mailing Address - Country:US
Mailing Address - Phone:509-744-1700
Mailing Address - Fax:
Practice Address - Street 1:9001 N COUNTRY HOMES BLVD
Practice Address - Street 2:
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99218-2072
Practice Address - Country:US
Practice Address - Phone:509-744-1700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-07-25
Last Update Date:2016-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant