Provider Demographics
NPI:1518107556
Name:TAKATANI, RYAN (PA)
Entity Type:Individual
Prefix:MR
First Name:RYAN
Middle Name:
Last Name:TAKATANI
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:10790 RANCHO BERNARDO RD
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92127-5705
Mailing Address - Country:US
Mailing Address - Phone:858-554-8984
Mailing Address - Fax:858-554-5055
Practice Address - Street 1:10670 JOHN J HOPKINS DR
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92121-1120
Practice Address - Country:US
Practice Address - Phone:858-554-8984
Practice Address - Fax:858-554-5055
Is Sole Proprietor?:No
Enumeration Date:2009-03-04
Last Update Date:2022-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA20060363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACE671ZMedicare PIN