Provider Demographics
NPI:1073039848
Name:MILLAR, RYAN KELLAN (PA-C)
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:KELLAN
Last Name:MILLAR
Suffix:
Gender:M
Credentials: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:PO BOX 63082
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28263-9688
Mailing Address - Country:US
Mailing Address - Phone:919-785-3400
Mailing Address - Fax:919-783-7778
Practice Address - Street 1:5838 SIX FORKS RD
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27609-3885
Practice Address - Country:US
Practice Address - Phone:919-785-3400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-14
Last Update Date:2024-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-07510363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant