Provider Demographics
NPI:1609569102
Name:PELTON, RYAN JOSEPH
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:JOSEPH
Last Name:PELTON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:55 MICHELLE DR
Mailing Address - Street 2:
Mailing Address - City:CLIFTON PARK
Mailing Address - State:NY
Mailing Address - Zip Code:12065-1671
Mailing Address - Country:US
Mailing Address - Phone:518-522-9186
Mailing Address - Fax:
Practice Address - Street 1:1694 US-9
Practice Address - Street 2:
Practice Address - City:CLIFTON PARK
Practice Address - State:NY
Practice Address - Zip Code:12065
Practice Address - Country:US
Practice Address - Phone:518-930-7486
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-31
Last Update Date:2023-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant