Healthcare Provider Details

I. General information

NPI: 1962805226
Provider Name (Legal Business Name): RYAN A. GILBRETH PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/01/2014
Last Update Date: 08/22/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19020 33RD AVE W STE 210
LYNNWOOD WA
98036-4748
US

IV. Provider business mailing address

19020 33RD AVE W STE 210
LYNNWOOD WA
98036-4748
US

V. Phone/Fax

Practice location:
  • Phone: 425-563-1500
  • Fax: 425-563-1501
Mailing address:
  • Phone: 425-563-1500
  • Fax: 425-563-1374

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number5857
License Number StateAZ
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA60938311
License Number StateWA
# 3
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number5857
License Number StateAZ
# 4
Primary TaxonomyN
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License NumberPA60938311
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: