Provider Demographics
NPI:1417265562
Name:RYAN, HEATHER (PA-C)
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:
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:PO BOX 7672
Mailing Address - Street 2:
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92658-7672
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:360 SAN MIGUEL DR
Practice Address - Street 2:SUITE 701
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92660-7853
Practice Address - Country:US
Practice Address - Phone:949-759-3600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-09-22
Last Update Date:2013-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA21194363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant