Provider Demographics
NPI:1912220112
Name:SHIN, SUNG RYAN (PA-C, DHSC)
Entity Type:Individual
Prefix:MR
First Name:SUNG
Middle Name:RYAN
Last Name:SHIN
Suffix:
Gender:M
Credentials:PA-C, DHSC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3833 FARR OAK CIR
Mailing Address - Street 2:
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22030-2438
Mailing Address - Country:US
Mailing Address - Phone:571-235-2828
Mailing Address - Fax:
Practice Address - Street 1:13880 BRADDOCK RD STE 107
Practice Address - Street 2:
Practice Address - City:CENTREVILLE
Practice Address - State:VA
Practice Address - Zip Code:20121-2460
Practice Address - Country:US
Practice Address - Phone:703-965-0180
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-03-02
Last Update Date:2018-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110003258363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0083533Medicaid
OH0083533Medicaid
OHH190800Medicare PIN