Provider Demographics
NPI:1619276789
Name:DADDS, RYAN MICHELLE (PA-C)
Entity Type:Individual
Prefix:MISS
First Name:RYAN
Middle Name:MICHELLE
Last Name:DADDS
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 1:3300 S FISKE BLVD
Mailing Address - Street 2:
Mailing Address - City:ROCKLEDGE
Mailing Address - State:FL
Mailing Address - Zip Code:32955-4306
Mailing Address - Country:US
Mailing Address - Phone:321-725-4505
Mailing Address - Fax:321-434-1981
Practice Address - Street 1:1223 GATEWAY DR
Practice Address - Street 2:1E
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32901
Practice Address - Country:US
Practice Address - Phone:321-725-4505
Practice Address - Fax:321-409-8932
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-15
Last Update Date:2020-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9109222363AS0400X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLIK121XOtherMEDICARE
FLPENDINGMedicaid
SCP00998178OtherRAILROAD MEDICARE ID-RSFPN