Basic Information
| Provider Information | |||||||||
| NPI: | 1174852693 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | NULPH | ||||||||
| FirstName: | RYAN | ||||||||
| MiddleName: | CASEY | ||||||||
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| Credential: | P.A.-C. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 12221 MERIT DR STE 1610 | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752512204 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2142171911 | ||||||||
| FaxNumber: | 2142171912 | ||||||||
| Practice Location | |||||||||
| Address1: | 12221 MERIT DR STE 1610 | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752512204 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2142171911 | ||||||||
| FaxNumber: | 2142171912 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/11/2009 | ||||||||
| LastUpdateDate: | 11/21/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 363A00000X | PA06696 | TX | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 283189301 | 05 | TX | MEDICAID | 283189302 | 05 | TX | MEDICAID | 283189303 | 05 | TX | MEDICAID |