Provider Demographics
NPI:1548425309
Name:RUIZ, JOSE ANTHONY (PA-C)
Entity Type:Individual
Prefix:MR
First Name:JOSE
Middle Name:ANTHONY
Last Name:RUIZ
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:PO BOX 221249
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28222-1249
Mailing Address - Country:US
Mailing Address - Phone:980-208-1704
Mailing Address - Fax:425-563-1374
Practice Address - Street 1:3623 LATROBE DR STE 216
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28211-2117
Practice Address - Country:US
Practice Address - Phone:704-332-1291
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-07-22
Last Update Date:2021-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA60528245363A00000X
NC001001538363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0350501OtherL&I-EVERGREEN RADIA
WA0350498OtherL&I-RADIA REST OF WA
NC0010-01538OtherNORTH CAROLINA MEDICAL BOARD
WA0350499OtherL&I-RADIA KING COUNTY
WA0350502OtherL&I-SWEDISH RADIA EDMONDS
WA2042991Medicaid