Provider Demographics
NPI:1932624350
Name:MUTH, RYAN KARY
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:KARY
Last Name:MUTH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:206 ANZIO RD
Mailing Address - Street 2:
Mailing Address - City:SEASIDE
Mailing Address - State:CA
Mailing Address - Zip Code:93955-6370
Mailing Address - Country:US
Mailing Address - Phone:1406-396-4757
Mailing Address - Fax:
Practice Address - Street 1:111 CROSSROADS BLVD
Practice Address - Street 2:
Practice Address - City:CARMEL
Practice Address - State:CA
Practice Address - Zip Code:93923-8615
Practice Address - Country:US
Practice Address - Phone:140-639-6475
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-07
Last Update Date:2017-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA54720363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant