Provider Demographics
NPI:1548769524
Name:RYAN, KEVIN MICHAEL (PA)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:MICHAEL
Last Name:RYAN
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 1:35 PEARL ST STE 100
Mailing Address - Street 2:
Mailing Address - City:BROCKTON
Mailing Address - State:MA
Mailing Address - Zip Code:02301-1195
Mailing Address - Country:US
Mailing Address - Phone:781-769-3222
Mailing Address - Fax:781-255-9807
Practice Address - Street 1:35 PEARL ST STE 200
Practice Address - Street 2:
Practice Address - City:BROCKTON
Practice Address - State:MA
Practice Address - Zip Code:02301-2866
Practice Address - Country:US
Practice Address - Phone:508-588-8034
Practice Address - Fax:508-897-0475
Is Sole Proprietor?:No
Enumeration Date:2018-02-06
Last Update Date:2023-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363AS0400X
MAPA7481363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical