Provider Demographics
NPI:1164854816
Name:WILSON, RYAN PATRICK (PA-C, MSPAS, MPH)
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:PATRICK
Last Name:WILSON
Suffix:
Gender:M
Credentials:PA-C, MSPAS, MPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 PARNASSUS AVE
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94143-2202
Mailing Address - Country:US
Mailing Address - Phone:415-353-2161
Mailing Address - Fax:
Practice Address - Street 1:400 PARNASSUS AVE
Practice Address - Street 2:A-655
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94143-2202
Practice Address - Country:US
Practice Address - Phone:415-353-2161
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-08-05
Last Update Date:2016-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA23120363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1112015OtherNCCPA
CAPA23120OtherCALIFORNIA PHYSICIAN ASSISTANT LICENSE