Provider Demographics
NPI:1760972400
Name:BLANCO, RYAN (PA)
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:
Last Name:BLANCO
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 1:1545 N LAS PALMAS AVE APT 12
Mailing Address - Street 2:
Mailing Address - City:HOLLYWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:90028-7126
Mailing Address - Country:US
Mailing Address - Phone:347-497-2205
Mailing Address - Fax:
Practice Address - Street 1:555 E HARDY ST
Practice Address - Street 2:
Practice Address - City:INGLEWOOD
Practice Address - State:CA
Practice Address - Zip Code:90301-4011
Practice Address - Country:US
Practice Address - Phone:310-673-4660
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-17
Last Update Date:2018-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant