Provider Demographics
NPI:1912566209
Name:HOM, RYAN MATTHEW (PA-C)
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:MATTHEW
Last Name:HOM
Suffix:
Gender:M
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:PO BOX 11013
Mailing Address - Street 2:
Mailing Address - City:BURBANK
Mailing Address - State:CA
Mailing Address - Zip Code:91510-1013
Mailing Address - Country:US
Mailing Address - Phone:818-669-1131
Mailing Address - Fax:
Practice Address - Street 1:814 FRANCISCO ST
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90017-2530
Practice Address - Country:US
Practice Address - Phone:310-491-7070
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-10
Last Update Date:2019-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA56865363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant