Basic Information
| Provider Information | |||||||||
| NPI: | 1053748020 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FALLT | ||||||||
| FirstName: | RYAN | ||||||||
| MiddleName: | P | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4900 S MONACO ST | ||||||||
| Address2: | #210 | ||||||||
| City: | DENVER | ||||||||
| State: | CO | ||||||||
| PostalCode: | 802373486 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7207544800 | ||||||||
| FaxNumber: | 7207544801 | ||||||||
| Practice Location | |||||||||
| Address1: | 2045 FRANKLIN ST | ||||||||
| Address2: | |||||||||
| City: | DENVER | ||||||||
| State: | CO | ||||||||
| PostalCode: | 802055494 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3038613302 | ||||||||
| FaxNumber: | 3038613498 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/04/2013 | ||||||||
| LastUpdateDate: | 02/11/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/11/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RH0003X | 3816 | CO | N | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology & Oncology | 363A00000X | 3816 | CO | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 64082881 | 05 | CO | MEDICAID |