Provider Demographics
NPI:1417151572
Name:GASSIN, RYAN T (MD)
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:T
Last Name:GASSIN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 505164
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63150-5164
Mailing Address - Country:US
Mailing Address - Phone:417-829-4620
Mailing Address - Fax:417-829-4316
Practice Address - Street 1:1235 E CHEROKEE ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65804-2203
Practice Address - Country:US
Practice Address - Phone:417-820-2829
Practice Address - Fax:417-820-8852
Is Sole Proprietor?:No
Enumeration Date:2007-06-13
Last Update Date:2024-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2011017817207L00000X
MN50823207L00000X
AZ42658207L00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNENROLLEDMedicaid
IAENROLLEDMedicaid
MO1417151572Medicaid
IAENROLLEDMedicaid
MO132680610Medicare PIN
MO132300564Medicare PIN
MNENROLLEDMedicaid