Provider Demographics
NPI:1497782106
Name:POWELL, RICKY A (PA-C)
Entity Type:Individual
Prefix:MR
First Name:RICKY
Middle Name:A
Last Name:POWELL
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 1:675 OLD BALLAS RD STE 100
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63141-7083
Mailing Address - Country:US
Mailing Address - Phone:314-733-9009
Mailing Address - Fax:
Practice Address - Street 1:675 OLD BALLAS RD STE 100
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63141-7083
Practice Address - Country:US
Practice Address - Phone:314-733-9009
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-27
Last Update Date:2021-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO114408363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO7836224OtherAETNA
MO385496OtherHEALTHLINK
MO122134OtherBLUE CROSS BLUE SHIELD
S58460Medicare UPIN
MO000085249Medicare PIN