Provider Demographics
NPI:1114594124
Name:TROUT, RYAN (PA-C)
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:
Last Name:TROUT
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 1:2046 W LAKE SHORE DR
Mailing Address - Street 2:
Mailing Address - City:PINOPOLIS
Mailing Address - State:SC
Mailing Address - Zip Code:29469-5043
Mailing Address - Country:US
Mailing Address - Phone:843-709-5392
Mailing Address - Fax:
Practice Address - Street 1:612 SEACOAST PKWY
Practice Address - Street 2:
Practice Address - City:MOUNT PLEASANT
Practice Address - State:SC
Practice Address - Zip Code:29464-8247
Practice Address - Country:US
Practice Address - Phone:843-881-4440
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-08
Last Update Date:2021-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical