Provider Demographics
NPI:1467478412
Name:RYAN, JAMIE MARTIN (PAC)
Entity Type:Individual
Prefix:MS
First Name:JAMIE
Middle Name:MARTIN
Last Name:RYAN
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:JAMIE
Other - Middle Name:ALLYSON
Other - Last Name:MARTIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PAC
Mailing Address - Street 1:507 S 4TH ST
Mailing Address - Street 2:
Mailing Address - City:GADSDEN
Mailing Address - State:AL
Mailing Address - Zip Code:35901
Mailing Address - Country:US
Mailing Address - Phone:256-547-7417
Mailing Address - Fax:256-547-7414
Practice Address - Street 1:507 S 4TH ST
Practice Address - Street 2:
Practice Address - City:GADSDEN
Practice Address - State:AL
Practice Address - Zip Code:35901
Practice Address - Country:US
Practice Address - Phone:256-547-7417
Practice Address - Fax:256-547-7414
Is Sole Proprietor?:No
Enumeration Date:2006-07-14
Last Update Date:2013-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALPA350363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL051518462Medicaid
ALPA350OtherSTATE MED LIC BD
ALPA350OtherSTATE MED LIC BD
Q00598Medicare UPIN