Provider Demographics
NPI:1205464344
Name:DIRIENZO, RYAN RENO (PA-C)
Entity type:Individual
Prefix:
First Name:RYAN
Middle Name:RENO
Last Name:DIRIENZO
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 1:1 ELDORADO DR APT D
Mailing Address - Street 2:
Mailing Address - City:TRUMANSBURG
Mailing Address - State:NY
Mailing Address - Zip Code:14886-9333
Mailing Address - Country:US
Mailing Address - Phone:860-543-5528
Mailing Address - Fax:
Practice Address - Street 1:16 BRENTWOOD DR
Practice Address - Street 2:
Practice Address - City:ITHACA
Practice Address - State:NY
Practice Address - Zip Code:14850-1863
Practice Address - Country:US
Practice Address - Phone:607-272-7000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-01
Last Update Date:2020-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NY025842-01363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Single Specialty