Provider Demographics
NPI:1124569710
Name:BALTHASER, RYAN PAUL (PA)
Entity Type:Individual
Prefix:MR
First Name:RYAN
Middle Name:PAUL
Last Name:BALTHASER
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 1:725 TIMPANY BLVD
Mailing Address - Street 2:
Mailing Address - City:GARDNER
Mailing Address - State:MA
Mailing Address - Zip Code:01440-3453
Mailing Address - Country:US
Mailing Address - Phone:978-632-8100
Mailing Address - Fax:
Practice Address - Street 1:725 TIMPANY BLVD
Practice Address - Street 2:
Practice Address - City:GARDNER
Practice Address - State:MA
Practice Address - Zip Code:01440-3453
Practice Address - Country:US
Practice Address - Phone:978-632-8100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-03-15
Last Update Date:2017-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAPA6065363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant