Healthcare Provider Details

I. General information

NPI: 1013555796
Provider Name (Legal Business Name): RYAN ESTELLE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/13/2019
Last Update Date: 07/10/2026
Certification Date: 07/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3820 S HUALAPAI WAY STE 200
LAS VEGAS NV
89147-5734
US

IV. Provider business mailing address

3820 S HUALAPAI WAY STE 200
LAS VEGAS NV
89147-5734
US

V. Phone/Fax

Practice location:
  • Phone: 702-960-4150
  • Fax: 702-960-4154
Mailing address:
  • Phone: 702-960-4150
  • Fax: 702-960-4154

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA3042
License Number StateNV
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA9112654
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: