Provider Demographics
NPI:1639729247
Name:RYAN, SKYLAR KRISTINE (PA-C)
Entity Type:Individual
Prefix:
First Name:SKYLAR
Middle Name:KRISTINE
Last Name:RYAN
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 1:2960 N LAINEY LN
Mailing Address - Street 2:
Mailing Address - City:BUCKEYE
Mailing Address - State:AZ
Mailing Address - Zip Code:85396-7326
Mailing Address - Country:US
Mailing Address - Phone:813-310-2524
Mailing Address - Fax:
Practice Address - Street 1:1008 E MCDOWELL RD STE A
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85006-2603
Practice Address - Country:US
Practice Address - Phone:602-358-8588
Practice Address - Fax:602-688-6991
Is Sole Proprietor?:No
Enumeration Date:2019-09-16
Last Update Date:2023-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ8251363A00000X
363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ096100Medicaid