Provider Demographics
NPI:1093315863
Name:KATIDES, RYAN JAMES (RN, CNP)
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:JAMES
Last Name:KATIDES
Suffix:
Gender:M
Credentials:RN, CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15 HALE ST
Mailing Address - Street 2:
Mailing Address - City:WEYMOUTH
Mailing Address - State:MA
Mailing Address - Zip Code:02189-1042
Mailing Address - Country:US
Mailing Address - Phone:617-750-3272
Mailing Address - Fax:
Practice Address - Street 1:300 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02108-4639
Practice Address - Country:US
Practice Address - Phone:617-363-5566
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-29
Last Update Date:2022-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN283478163WE0003X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163WE0003XNursing Service ProvidersRegistered NurseEmergency