Provider Demographics
NPI:1598712572
Name:CLEMENT, RYAN DAVID (PA-C)
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:DAVID
Last Name:CLEMENT
Suffix:
Gender:M
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 5105
Mailing Address - Street 2:
Mailing Address - City:BELFAST
Mailing Address - State:ME
Mailing Address - Zip Code:04915-5100
Mailing Address - Country:US
Mailing Address - Phone:919-220-5255
Mailing Address - Fax:
Practice Address - Street 1:3100 DURALEIGH RD
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27612-8106
Practice Address - Country:US
Practice Address - Phone:919-220-5255
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-27
Last Update Date:2023-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC102770363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MC0372603OtherDEA
NC2753070BMedicare PIN
P27445Medicare UPIN