NPIMap

Individual provider Active NPI

Ryan J Nettles, PA-C

  • Physician Assistant
  • Leawood, KS
National Provider Identifier
1003814849
Registry record updated Jun 6, 2011
On this page

Key facts

NPPES NPI Registry
Primary specialty
Physician AssistantTaxonomy code 363A00000X
License
PA-2940 Issued in CO
Practice address
3651 College Blvd
#100A
Leawood, KS 66211-1904
Phone
(913) 319-7546
Fax
(913) 319-7691
NPI assigned
Jul 13, 2005
Sex
Male
Sole proprietor
No

NPPES NPI Registry

Updated by the provider on Jun 6, 2011

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 3

Specialty (taxonomy)CodeLicenseStatePrimary
Physician Assistant 363A00000X 05-25395 KS
Physician Assistant 363A00000X 2004027792 MO
Physician Assistant 363A00000X PA-2940 CO Primary

Addresses

Primary practice location

3651 College Blvd
#100A
Leawood, KS 66211-1904

Mailing address

3651 College Blvd
#100A
Leawood, KS 66211-1904
Phone (913) 319-7546

Other identifiers 1

IdentifierTypeStateIssuer
61037729MedicaidCO

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in CO
Eligible to order & refer
  • Part B services
  • Medical equipment
  • Home health
  • Power mobility devices
  • Hospice
Green means eligible to order or refer.

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
I20100324000206 CO Practitioner - Physician Assistant 0143284158 Reassigns benefits to 2 organizations

Care Compare profile

Medicare Care Compare
Specialty
Physician Assistant
Education
Other, 2004
Medicare assignment
Accepts the Medicare-approved amount as payment in full
Group practices
Banner Health Physicians Colorado LLCGroup PAC ID 8921273038, 278 clinicians

Practice addresses (Care Compare)

1801 16TH St
Greeley, CO 80631-5154
Phone (970) 810-4121

5890 W 13TH St
Greeley, CO 80634-4821

Hospital & facility affiliations

  • Banner North Colorado Medical Center Hospital, Greeley, CO, CCN 060001

National Provider Directory

National Provider Directory
Medicare enrollment (NPD)
Enrolled
Credentials
Physician Assistant

State licenses

LicenseStateTypeSpecialty
PA-2940COMDPhysician Assistant
05-25395KSMDPhysician Assistant
2004027792MOMDPhysician Assistant

Practice roles

OrganizationSpecialtyStatusNew patients
Banner Health Physicians Colorado LLC CurrentSince Oct 1, 2012 Accepting new patients
Banner Hospital Based Physicians Colorado LLC CurrentSince May 13, 2020 Accepting new patients
Banner Health Physicians Colorado LLC CurrentSince Oct 1, 2012 Accepting new patients
Banner Hospital Based Physicians Colorado LLC CurrentSince May 13, 2020 Accepting new patients
Banner Health Physicians Colorado LLC Past Accepting new patients

Locations

1801 16th St
Ste C2B
Greeley, CO 80631
Phone (970) 810-4121

5890 W 13th St
Ste 101
Greeley, CO 80634
Phone (970) 348-0020

1801 16th St
Greeley, CO 80631
Phone (970) 352-4121

Organizations & group practices 5

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.

Hospital & facility affiliations 12

Hospitals and other facilities this clinician is affiliated with according to Medicare Care Compare.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1121212800000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1307318400000",
    "number": "1003814849",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "3651 COLLEGE BLVD",
            "address_2": "#100A",
            "city": "LEAWOOD",
            "state": "KS",
            "postal_code": "662111904",
            "telephone_number": "913-319-7546",
            "fax_number": "913-319-7691"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "3651 COLLEGE BLVD",
            "address_2": "#100A",
            "city": "LEAWOOD",
            "state": "KS",
            "postal_code": "662111904",
            "telephone_number": "913-319-7546",
            "fax_number": "913-319-7691"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "NETTLES",
        "first_name": "RYAN",
        "middle_name": "J",
        "credential": "PA-C",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2005-07-13",
        "last_updated": "2011-06-06",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "363A00000X",
            "taxonomy_group": "",
            "desc": "Physician Assistant",
            "state": "KS",
            "license": "05-25395",
            "primary": false
        },
        {
            "code": "363A00000X",
            "taxonomy_group": "",
            "desc": "Physician Assistant",
            "state": "MO",
            "license": "2004027792",
            "primary": false
        },
        {
            "code": "363A00000X",
            "taxonomy_group": "",
            "desc": "Physician Assistant",
            "state": "CO",
            "license": "PA-2940",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "61037729",
            "state": "CO"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Leawood, KS

Sources for this page

Verify at the official NPI Registry.