Provider Demographics
NPI:1588213250
Name:PITALO, RYAN N (HIS)
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:N
Last Name:PITALO
Suffix:
Gender:M
Credentials:HIS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:120 CAILLAVET ST
Mailing Address - Street 2:
Mailing Address - City:BILOXI
Mailing Address - State:MS
Mailing Address - Zip Code:39530-4102
Mailing Address - Country:US
Mailing Address - Phone:228-432-7071
Mailing Address - Fax:228-432-7910
Practice Address - Street 1:120 CAILLAVET ST
Practice Address - Street 2:
Practice Address - City:BILOXI
Practice Address - State:MS
Practice Address - Zip Code:39530-4102
Practice Address - Country:US
Practice Address - Phone:228-432-7071
Practice Address - Fax:228-432-7910
Is Sole Proprietor?:No
Enumeration Date:2019-09-05
Last Update Date:2019-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSHA0603237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist