Provider Demographics
NPI:1811558943
Name:RYAN, KAELLY ANN (PA-C)
Entity Type:Individual
Prefix:
First Name:KAELLY
Middle Name:ANN
Last Name:RYAN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:KAELLY
Other - Middle Name:ANN
Other - Last Name:MILLER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:1000 STATE ST # 55
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:01109-3151
Mailing Address - Country:US
Mailing Address - Phone:443-487-3351
Mailing Address - Fax:
Practice Address - Street 1:1000 STATE ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MA
Practice Address - Zip Code:01109-3151
Practice Address - Country:US
Practice Address - Phone:413-205-3248
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-28
Last Update Date:2022-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant