Individual
MR. RYAN C. WALLENTINE
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
PA-AA
Contact information
Practice address
380 HOSPITAL DR, SUITE 410, MACON, GA 31217
(478) 746-5644
(478) 745-4849
Mailing address
PO BOX 2564, MACON, GA 31203-2564
(478) 746-5644
(478) 745-4849
Taxonomy
Speciality
Code
Description
License number
State
367H00000X
Anesthesiologist Assistant
Primary
006279
GA
367H00000X
Anesthesiologist Assistant
—
GA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
003114063A
—
GA
05
—
003114063B
—
GA
05
—
003114063C
—
GA
05
—
003114063D
—
GA
01
—
580628385
TRICARE
GA
01
—
635417
WELLCARE
GA
01
—
P01003812
RAILROAD MEDICARE
GA
Enumeration date
09/12/2011
Last updated
06/04/2013
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