Provider Demographics
NPI:1407484900
Name:BADER, PAUL RYAN (PA)
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:RYAN
Last Name:BADER
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3889
Mailing Address - Street 2:
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37602-3889
Mailing Address - Country:US
Mailing Address - Phone:423-794-1800
Mailing Address - Fax:423-794-1801
Practice Address - Street 1:101 MED TECH PKWY STE 100
Practice Address - Street 2:
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37604-4006
Practice Address - Country:US
Practice Address - Phone:423-794-1800
Practice Address - Fax:423-794-1801
Is Sole Proprietor?:No
Enumeration Date:2020-03-30
Last Update Date:2021-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN4187363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant