Provider Demographics
NPI:1407302920
Name:RYAN, JOCELYN NICOLE (PA-C)
Entity Type:Individual
Prefix:
First Name:JOCELYN
Middle Name:NICOLE
Last Name:RYAN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:960 MASSACHUSETTS AVENUE
Mailing Address - Street 2:FL 2
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02118-2690
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:840 HARRISON AVE
Practice Address - Street 2:MENINO BUILDING
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02118
Practice Address - Country:US
Practice Address - Phone:617-638-8605
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-26
Last Update Date:2024-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT003647363A00000X
MAPA5843363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110132178AMedicaid