Provider Demographics
NPI:1326132838
Name:RYAN, TIMOTHY L (PHYSICIAN ASSISTANT)
Entity Type:Individual
Prefix:MR
First Name:TIMOTHY
Middle Name:L
Last Name:RYAN
Suffix:
Gender:M
Credentials:PHYSICIAN ASSISTANT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:601 ELMWOOD AVENUE
Mailing Address - Street 2:BOX 648
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14642
Mailing Address - Country:US
Mailing Address - Phone:585-275-0099
Mailing Address - Fax:575-273-1033
Practice Address - Street 1:601 ELMWOOD AVENUE
Practice Address - Street 2:BOX 648
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14642
Practice Address - Country:US
Practice Address - Phone:585-275-0099
Practice Address - Fax:575-273-1033
Is Sole Proprietor?:No
Enumeration Date:2006-10-02
Last Update Date:2009-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY007119363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant