Provider Demographics
NPI:1235340829
Name:RUST, RYAN ANTHONY (PA-C)
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:ANTHONY
Last Name:RUST
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 1:1420 NORMANDY DR
Mailing Address - Street 2:
Mailing Address - City:CHULA VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:91913-3903
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:9040 FRIARS RD
Practice Address - Street 2:STE. 230
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92108-5859
Practice Address - Country:US
Practice Address - Phone:619-284-6377
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-24
Last Update Date:2021-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA 16805363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant