Provider Demographics
NPI:1275616070
Name:RYAN, JOHN PATRICK IV (PHYSICIAN ASSISTANT)
Entity Type:Individual
Prefix:MR
First Name:JOHN
Middle Name:PATRICK
Last Name:RYAN
Suffix:IV
Gender:M
Credentials:PHYSICIAN ASSISTANT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Mailing Address - Street 1:70 VALLEY DR
Mailing Address - Street 2:
Mailing Address - City:W SAND LAKE
Mailing Address - State:NY
Mailing Address - Zip Code:12196-1739
Mailing Address - Country:US
Mailing Address - Phone:518-674-5041
Mailing Address - Fax:
Practice Address - Street 1:43 NEW SCOTLAND AVE
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:NY
Practice Address - Zip Code:12208-3478
Practice Address - Country:US
Practice Address - Phone:518-262-3494
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-23
Last Update Date:2019-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY090042363A00000X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant