Provider Demographics
NPI:1114209525
Name:WALLENTINE, RYAN C (PA-AA)
Entity Type:Individual
Prefix:MR
First Name:RYAN
Middle Name:C
Last Name:WALLENTINE
Suffix:
Gender:M
Credentials:PA-AA
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 2564
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31203-2564
Mailing Address - Country:US
Mailing Address - Phone:478-746-5644
Mailing Address - Fax:478-745-4849
Practice Address - Street 1:380 HOSPITAL DR
Practice Address - Street 2:SUITE 410
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31217
Practice Address - Country:US
Practice Address - Phone:478-746-5644
Practice Address - Fax:478-745-4849
Is Sole Proprietor?:No
Enumeration Date:2011-09-12
Last Update Date:2013-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA367H00000X
GA006279367H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367H00000XPhysician Assistants & Advanced Practice Nursing ProvidersAnesthesiologist Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA580628385OtherTRICARE
GAP01003812OtherRAILROAD MEDICARE
GA003114063CMedicaid
GA003114063DMedicaid
GA003114063BMedicaid
GA003114063AMedicaid
GA635417OtherWELLCARE
GAP01003812OtherRAILROAD MEDICARE