Healthcare Provider Details

I. General information

NPI: 1225857394
Provider Name (Legal Business Name): RYAN SALT PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/07/2024
Last Update Date: 01/24/2025
Certification Date: 01/24/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13975 MONO WAY STE G
SONORA CA
95370-2824
US

IV. Provider business mailing address

7314 WESTERLY WAY
EASTVALE CA
92880-9089
US

V. Phone/Fax

Practice location:
  • Phone: 209-533-9600
  • Fax: 209-533-9608
Mailing address:
  • Phone: 714-262-6438
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA10736
License Number StateAZ
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA65267
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: