Provider Demographics
NPI:1760016000
Name:OUILLETTE, RYAN
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:
Last Name:OUILLETTE
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 1:100 UCLA MEDICAL PLZ STE 170
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90024-7001
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:100 UCLA MEDICAL PLZ STE 170
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90024-7001
Practice Address - Country:US
Practice Address - Phone:858-534-3880
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-25
Last Update Date:2022-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA7776207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty