Provider Demographics
NPI:1134655152
Name:NELSON, RYAN ALEXANDER (PA-C)
Entity type:Individual
Prefix:
First Name:RYAN
Middle Name:ALEXANDER
Last Name:NELSON
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 1:1285 CREEKSIDE BLVD E UNIT 102
Mailing Address - Street 2:
Mailing Address - City:NAPLES
Mailing Address - State:FL
Mailing Address - Zip Code:34109-0595
Mailing Address - Country:US
Mailing Address - Phone:239-624-1700
Mailing Address - Fax:239-624-0311
Practice Address - Street 1:1285 CREEKSIDE BLVD E UNIT 102
Practice Address - Street 2:
Practice Address - City:NAPLES
Practice Address - State:FL
Practice Address - Zip Code:34109-0595
Practice Address - Country:US
Practice Address - Phone:239-624-1700
Practice Address - Fax:239-624-0311
Is Sole Proprietor?:No
Enumeration Date:2017-05-11
Last Update Date:2025-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN12496363A00000X
FLPA9113002363AM0700X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLQIJMQOtherBCBS
FL108562100Medicaid