Provider Demographics
NPI:1093841959
Name:RYAN, TERESA LYNN (PA)
Entity Type:Individual
Prefix:
First Name:TERESA
Middle Name:LYNN
Last Name:RYAN
Suffix:
Gender:F
Credentials:PA
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Other - First Name:
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Mailing Address - Street 1:4840 E INDIAN SCHOOL RD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85018-5500
Mailing Address - Country:US
Mailing Address - Phone:602-508-2900
Mailing Address - Fax:602-952-9432
Practice Address - Street 1:4840 E INDIAN SCHOOL RD
Practice Address - Street 2:SUITE 100
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85018-5500
Practice Address - Country:US
Practice Address - Phone:602-508-2900
Practice Address - Fax:602-952-9432
Is Sole Proprietor?:No
Enumeration Date:2007-02-26
Last Update Date:2007-07-08
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
AZ1192363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ310805Medicaid
AZ310805Medicaid