Provider Demographics
NPI:1811221617
Name:LESTER, RYAN DOUGLAS (PA)
Entity Type:Individual
Prefix:MR
First Name:RYAN
Middle Name:DOUGLAS
Last Name:LESTER
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 1:4611 GUADALUPE STREET
Mailing Address - Street 2:SUITE 200
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78704
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4611 GUADALUPE STREET
Practice Address - Street 2:SUITE 200
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78704
Practice Address - Country:US
Practice Address - Phone:512-476-2830
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-09-25
Last Update Date:2012-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY013519363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03332276Medicaid
J400045484Medicare PIN