Provider Demographics
NPI:1548709009
Name:ROE, RYAN C (PA-C)
Entity type:Individual
Prefix:
First Name:RYAN
Middle Name:C
Last Name:ROE
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O. BOX 7399
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78713-7399
Mailing Address - Country:US
Mailing Address - Phone:512-471-4245
Mailing Address - Fax:
Practice Address - Street 1:405 EAST 23RD STREET
Practice Address - Street 2:P1.030
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78712
Practice Address - Country:US
Practice Address - Phone:512-471-4245
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-02-16
Last Update Date:2021-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN3592363A00000X
TX363A00000X
TXPA11199363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ038416Medicaid