Provider Demographics
NPI:1821599143
Name:SEIDL, RYAN WAYNE
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:WAYNE
Last Name:SEIDL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:RYAN
Other - Middle Name:WAYNE
Other - Last Name:FRY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 751649
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28275-1649
Mailing Address - Country:US
Mailing Address - Phone:843-789-1620
Mailing Address - Fax:843-724-2440
Practice Address - Street 1:149 SAINT JAMES AVE
Practice Address - Street 2:
Practice Address - City:GOOSE CREEK
Practice Address - State:SC
Practice Address - Zip Code:29445-2923
Practice Address - Country:US
Practice Address - Phone:843-266-3430
Practice Address - Fax:843-266-1997
Is Sole Proprietor?:No
Enumeration Date:2018-02-22
Last Update Date:2018-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC2852363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant