Provider Demographics
NPI:1275627606
Name:TOLIVER, RYAN D (PA-C)
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:D
Last Name:TOLIVER
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 1:545 BRANSON LANDING BLVD
Mailing Address - Street 2:STE 306
Mailing Address - City:BRANSON
Mailing Address - State:MO
Mailing Address - Zip Code:65616
Mailing Address - Country:US
Mailing Address - Phone:417-336-9728
Mailing Address - Fax:417-337-9710
Practice Address - Street 1:545 BRANSON LANDING BLVD
Practice Address - Street 2:STE 306
Practice Address - City:BRANSON
Practice Address - State:MO
Practice Address - Zip Code:65616
Practice Address - Country:US
Practice Address - Phone:417-336-9728
Practice Address - Fax:417-337-9710
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-02
Last Update Date:2007-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2006009296363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
190995OtherBCBS
P00390693OtherRAILROAD MEDICARE
26576OtherBCBS
115799OtherBCBS