Healthcare Provider Details

I. General information

NPI: 1134770811
Provider Name (Legal Business Name): MR. RYAN MICHAEL OCONNELL
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/24/2019
Last Update Date: 07/08/2025
Certification Date: 07/08/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1401 W 1ST ST
SANTA ANA CA
92703-3757
US

IV. Provider business mailing address

610 LAGUNA RD
FULLERTON CA
92835-2434
US

V. Phone/Fax

Practice location:
  • Phone: 714-542-9700
  • Fax: 714-542-9708
Mailing address:
  • Phone: 858-291-2503
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA58938
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: