Provider Demographics
NPI:1639838337
Name:ERTL, RYLIE JO (PA-C)
Entity type:Individual
Prefix:
First Name:RYLIE
Middle Name:JO
Last Name:ERTL
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:RYLIE
Other - Middle Name:JO
Other - Last Name:HOLCOMB
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:491 ALLENDALE RD
Mailing Address - Street 2:STE 104
Mailing Address - City:KING OF PRUSSIA
Mailing Address - State:PA
Mailing Address - Zip Code:19406-9990
Mailing Address - Country:US
Mailing Address - Phone:610-563-0950
Mailing Address - Fax:
Practice Address - Street 1:11 FRIENDS LANE
Practice Address - Street 2:STE. 101
Practice Address - City:NEWTOWN
Practice Address - State:PA
Practice Address - Zip Code:18940-1885
Practice Address - Country:US
Practice Address - Phone:610-563-0950
Practice Address - Fax:352-333-0990
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-10
Last Update Date:2024-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA065687363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL9TUAKOtherBCBS
FL1132746-00Medicaid