Provider Demographics
NPI:1083479620
Name:RYAN, ALEXANDRA GRAY
Entity Type:Individual
Prefix:MISS
First Name:ALEXANDRA
Middle Name:GRAY
Last Name:RYAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4710 HARD SCUFFLE LN
Mailing Address - Street 2:
Mailing Address - City:HOLLYWOOD
Mailing Address - State:SC
Mailing Address - Zip Code:29449-5781
Mailing Address - Country:US
Mailing Address - Phone:854-500-6432
Mailing Address - Fax:
Practice Address - Street 1:4710 HARD SCUFFLE LN
Practice Address - Street 2:
Practice Address - City:HOLLYWOOD
Practice Address - State:SC
Practice Address - Zip Code:29449-5781
Practice Address - Country:US
Practice Address - Phone:854-500-6432
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-02-13
Last Update Date:2024-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant