Provider Demographics
NPI:1013106038
Name:VANN, RYAN CARPENTER (PA-C)
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:CARPENTER
Last Name:VANN
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 344
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27102-0344
Mailing Address - Country:US
Mailing Address - Phone:336-716-2255
Mailing Address - Fax:336-940-2561
Practice Address - Street 1:147 PEACHTREE LANE
Practice Address - Street 2:
Practice Address - City:ADVANCE
Practice Address - State:NC
Practice Address - Zip Code:27006-6907
Practice Address - Country:US
Practice Address - Phone:336-716-2255
Practice Address - Fax:336-940-2561
Is Sole Proprietor?:No
Enumeration Date:2007-10-16
Last Update Date:2010-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-01085363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC2759012AMedicare PIN