Provider Demographics
NPI:1003457490
Name:RYAN, VICTORIA (PA-C)
Entity type:Individual
Prefix:
First Name:VICTORIA
Middle Name:
Last Name:RYAN
Suffix:
Gender:F
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 1:2509 S. POWER RD.
Mailing Address - Street 2:STE. 115
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85209
Mailing Address - Country:US
Mailing Address - Phone:724-933-0300
Mailing Address - Fax:
Practice Address - Street 1:2509 S. POWER RD.
Practice Address - Street 2:STE. 115
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85209
Practice Address - Country:US
Practice Address - Phone:724-933-0300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-07
Last Update Date:2024-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363AM0700X
AZ7995208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1093733933OtherGROUP NPI