Provider Demographics
NPI:1629884325
Name:RYAN, SHANTI (PA-C)
Entity type:Individual
Prefix:
First Name:SHANTI
Middle Name:
Last Name:RYAN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:3915 E CAMELBACK RD
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85018-2633
Mailing Address - Country:US
Mailing Address - Phone:928-533-8513
Mailing Address - Fax:
Practice Address - Street 1:3822 SE POWELL BLVD
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97202-1720
Practice Address - Country:US
Practice Address - Phone:888-227-3312
Practice Address - Fax:503-717-9966
Is Sole Proprietor?:No
Enumeration Date:2024-12-06
Last Update Date:2025-11-04
Deactivation Date:
Deactivation Code:
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Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1234509OtherCERTIFICATION
WAPA70046563OtherLICENSE