Provider Demographics
NPI:1629384268
Name:GROTH, RYAN EDWARD (PA)
Entity Type:Individual
Prefix:MR
First Name:RYAN
Middle Name:EDWARD
Last Name:GROTH
Suffix:
Gender:M
Credentials:PA
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 484
Mailing Address - Street 2:
Mailing Address - City:EASLEY
Mailing Address - State:SC
Mailing Address - Zip Code:29641-0484
Mailing Address - Country:US
Mailing Address - Phone:864-546-4497
Mailing Address - Fax:864-546-4506
Practice Address - Street 1:2561 HENDERSONVILLE RD
Practice Address - Street 2:
Practice Address - City:ARDEN
Practice Address - State:NC
Practice Address - Zip Code:28704-9577
Practice Address - Country:US
Practice Address - Phone:828-676-3234
Practice Address - Fax:828-676-3238
Is Sole Proprietor?:No
Enumeration Date:2010-08-20
Last Update Date:2017-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC001004408363A00000X
SC1604363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1629384268Medicaid
NCNCK423D870Medicare PIN