Provider Demographics
NPI:1285825208
Name:RYAN, BRANDON (PA-C, NREMT-P)
Entity Type:Individual
Prefix:
First Name:BRANDON
Middle Name:
Last Name:RYAN
Suffix:
Gender:M
Credentials:PA-C, NREMT-P
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:202 VILLAGE RD NE
Mailing Address - Street 2:
Mailing Address - City:LELAND
Mailing Address - State:NC
Mailing Address - Zip Code:28451-7414
Mailing Address - Country:US
Mailing Address - Phone:910-782-3600
Mailing Address - Fax:
Practice Address - Street 1:202 VILLAGE RD NE
Practice Address - Street 2:
Practice Address - City:LELAND
Practice Address - State:NC
Practice Address - Zip Code:28451-7414
Practice Address - Country:US
Practice Address - Phone:910-782-3600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-08-06
Last Update Date:2019-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCP071746146L00000X
GA6611146L00000X
NC0010-01834363A00000X, 363AM0700X
TXPA06145363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No146L00000XEmergency Medical Service ProvidersEmergency Medical Technician, Paramedic
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC0850PAMedicaid
NCP00780675OtherRAILROAD MEDICARE
NC1285825208OtherCHAMPUS
NC2760144Medicare PIN