Provider Demographics
NPI:1639838337
Name:ERTL, RYLIE JO
Entity Type:Individual
Prefix:
First Name:RYLIE
Middle Name:JO
Last Name:ERTL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:RYLIE
Other - Middle Name:JO
Other - Last Name:HOLCOMB
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:6716 NW 11TH PL STE 200
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32605-4201
Mailing Address - Country:US
Mailing Address - Phone:352-313-6825
Mailing Address - Fax:
Practice Address - Street 1:6716 NW 11TH PL STE 200
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32605-4201
Practice Address - Country:US
Practice Address - Phone:352-313-6825
Practice Address - Fax:352-333-0990
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-10
Last Update Date:2024-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9115340363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL9TUAKOtherBCBS
FL1132746-00Medicaid