Provider Demographics
NPI:1043207459
Name:NAKASONE, RYAN HISASHI (DC, PA-C)
Entity Type:Individual
Prefix:DR
First Name:RYAN
Middle Name:HISASHI
Last Name:NAKASONE
Suffix:
Gender:M
Credentials:DC, PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1100 PASEO CAMARILLO
Mailing Address - Street 2:
Mailing Address - City:CAMARILLO
Mailing Address - State:CA
Mailing Address - Zip Code:93010-6073
Mailing Address - Country:US
Mailing Address - Phone:805-895-5984
Mailing Address - Fax:
Practice Address - Street 1:1100 PASEO CAMARILLO
Practice Address - Street 2:
Practice Address - City:CAMARILLO
Practice Address - State:CA
Practice Address - Zip Code:93010-6073
Practice Address - Country:US
Practice Address - Phone:805-895-5984
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-30
Last Update Date:2016-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC-24909111N00000X
CAPA22126363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
U68010Medicare UPIN
CADC24909Medicare ID - Type Unspecified