Healthcare Provider Details

I. General information

NPI: 1841915139
Provider Name (Legal Business Name): AMBROSE TUMAINI RYAN PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/10/2022
Last Update Date: 08/30/2024
Certification Date: 08/30/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18523 CORWIN RD STE H
APPLE VALLEY CA
92307-2300
US

IV. Provider business mailing address

15237 ELEVENTH ST STE A
VICTORVILLE CA
92395-3736
US

V. Phone/Fax

Practice location:
  • Phone: 760-242-3005
  • Fax: 760-503-1375
Mailing address:
  • Phone: 760-662-7420
  • Fax: 760-513-9000

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA61554
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: