Provider Demographics
NPI:1053748020
Name:FALLT, RYAN P (PA-C)
Entity type:Individual
Prefix:
First Name:RYAN
Middle Name:P
Last Name:FALLT
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:4900 S MONACO ST
Mailing Address - Street 2:#210
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80237-3486
Mailing Address - Country:US
Mailing Address - Phone:720-754-4800
Mailing Address - Fax:720-754-4801
Practice Address - Street 1:2045 FRANKLIN ST
Practice Address - Street 2:
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80205-5494
Practice Address - Country:US
Practice Address - Phone:303-861-3302
Practice Address - Fax:303-861-3498
Is Sole Proprietor?:No
Enumeration Date:2013-10-04
Last Update Date:2022-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO3816207RH0003X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO64082881Medicaid
CO317618YTNRMedicare PIN