MEDICARE: RYAN J NETTLES PA-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant	05-25395	KS
2	363A00000X	Physician Assistant	2004027792	MO
3	363A00000X	Physician Assistant	PA-2940	CO

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1003814849
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	RYAN J NETTLES PA-C

Provider Business Mailing Address
First Line	:	3651 COLLEGE BLVD
Second Line	:	#100A
City	:	LEAWOOD
State	:	KS
Zip	:	66211-1904
Country	:	US
Telephone Number	:	913-319-7546
Fax Number	:	913-319-7691

Provider Business Practice Location Address
First Line	:	3651 COLLEGE BLVD
Second Line	:	#100A
City	:	LEAWOOD
State	:	KS
Zip	:	66211-1904
Country	:	US
Telephone Number	:	913-319-7546
Fax Number	:	913-319-7691

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/13/2005
Last Update Date	:	06/06/2011

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Directions to “ RYAN J NETTLES PA-C” Practice Location

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