Provider Demographics
NPI:1164963153
Name:VALLO, RYAN JOSEPH (PA-C, ATC)
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:JOSEPH
Last Name:VALLO
Suffix:
Gender:M
Credentials:PA-C, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1390 US HIGHWAY 61 STE G1000
Mailing Address - Street 2:
Mailing Address - City:FESTUS
Mailing Address - State:MO
Mailing Address - Zip Code:63028-4136
Mailing Address - Country:US
Mailing Address - Phone:636-933-7400
Mailing Address - Fax:636-933-7403
Practice Address - Street 1:1390 US HIGHWAY 61 STE G1000
Practice Address - Street 2:
Practice Address - City:FESTUS
Practice Address - State:MO
Practice Address - Zip Code:63028-4136
Practice Address - Country:US
Practice Address - Phone:636-933-7400
Practice Address - Fax:636-933-7403
Is Sole Proprietor?:No
Enumeration Date:2017-03-10
Last Update Date:2022-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2017007596363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical