Provider Demographics
NPI:1932517166
Name:HENTKOWSKI, RYAN P (PA-C)
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:P
Last Name:HENTKOWSKI
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:6800 SOUTHPOINT PKWY STE 300
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32216-8203
Mailing Address - Country:US
Mailing Address - Phone:904-634-0640
Mailing Address - Fax:904-634-0203
Practice Address - Street 1:4565 US HIGHWAY 17 STE 200
Practice Address - Street 2:
Practice Address - City:FLEMING ISLAND
Practice Address - State:FL
Practice Address - Zip Code:32003-4823
Practice Address - Country:US
Practice Address - Phone:904-634-0640
Practice Address - Fax:904-634-0203
Is Sole Proprietor?:No
Enumeration Date:2014-07-31
Last Update Date:2023-10-06
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FL363A00000X
FLPA9108073363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant