Provider Demographics
NPI:1730538216
Name:BALYAN, RITA
Entity type:Individual
Prefix:
First Name:RITA
Middle Name:
Last Name:BALYAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:360 SAN MIGUEL DR STE 501
Mailing Address - Street 2:
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92660-7831
Mailing Address - Country:US
Mailing Address - Phone:949-720-1170
Mailing Address - Fax:949-720-1172
Practice Address - Street 1:360 SAN MIGUEL DR STE 501
Practice Address - Street 2:
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92660-7831
Practice Address - Country:US
Practice Address - Phone:949-720-1170
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-06
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA53734363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant