Healthcare Provider Details

I. General information

NPI: 1497612410
Provider Name (Legal Business Name): RYDER PENTAGHAST
Entity Type: Individual
Gender:
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/09/2026
Last Update Date: 01/09/2026
Certification Date: 01/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

134 N WASHINGTON ST STE 3
SONORA CA
95370-4756
US

IV. Provider business mailing address

134 N WASHINGTON ST STE 3
SONORA CA
95370-4756
US

V. Phone/Fax

Practice location:
  • Phone: 209-288-2357
  • Fax:
Mailing address:
  • Phone: 209-288-2357
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: