Healthcare Provider Details

I. General information

NPI: 1679920144
Provider Name (Legal Business Name): RYAN TIMOTHY MINTON PAC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/15/2016
Last Update Date: 04/20/2026
Certification Date: 04/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

131 S APPLE BLOSSOM DR UNIT 104
CHELAN WA
98816-8827
US

IV. Provider business mailing address

230 PROSPECT ST
LEAVENWORTH WA
98826-1029
US

V. Phone/Fax

Practice location:
  • Phone: 509-682-3300
  • Fax: 509-682-3475
Mailing address:
  • Phone: 406-599-4312
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA60797366
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: