=====================================================
General NPI Number Information
=====================================================
NPI Number | 1659643534
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | RYAN THOMAS GONCE MPAS, PA-C
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/07/2012
-----------------------------------------------------
Last Update Date | 04/07/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1007 39TH AVE SE
-----------------------------------------------------
City | PUYALLUP
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98374-2192
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 253-435-3100
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1007 39TH AVE SE
-----------------------------------------------------
City | PUYALLUP
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98374-2192
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 253-435-3100
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363AM0700X
-----------------------------------------------------
Taxonomy Name | Medical Physician Assistant
-----------------------------------------------------
License Number | PA164883
-----------------------------------------------------
License Number State | OR
-----------------------------------------------------