Healthcare Provider Details

I. General information

NPI: 1750306007
Provider Name (Legal Business Name): RYAN O'NEAL P.A.-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/13/2006
Last Update Date: 12/23/2022
Certification Date: 12/23/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2767 JANITELL RD
COLORADO SPRINGS CO
80906-4102
US

IV. Provider business mailing address

2695 ROCKY MOUNTAIN AVE STE 150
LOVELAND CO
80538-9071
US

V. Phone/Fax

Practice location:
  • Phone: 719-365-2888
  • Fax: 719-365-1577
Mailing address:
  • Phone: 970-624-2417
  • Fax: 970-652-2927

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0110002096
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number1030
License Number StateNE
# 3
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA.0004596
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: