Provider Demographics
NPI:1356921308
Name:RYAN, CAITLYN MALLORY (PA-C)
Entity type:Individual
Prefix:
First Name:CAITLYN
Middle Name:MALLORY
Last Name:RYAN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:CAITLYN
Other - Middle Name:MALLORY
Other - Last Name:PACINA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:3300 S FISKE BLVD
Mailing Address - Street 2:
Mailing Address - City:ROCKLEDGE
Mailing Address - State:FL
Mailing Address - Zip Code:32955-4306
Mailing Address - Country:US
Mailing Address - Phone:321-312-3311
Mailing Address - Fax:321-952-0850
Practice Address - Street 1:1223 GATEWAY DR STE 1G
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32901-2607
Practice Address - Country:US
Practice Address - Phone:321-312-3311
Practice Address - Fax:321-952-0850
Is Sole Proprietor?:No
Enumeration Date:2021-04-13
Last Update Date:2023-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9116135363A00000X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLQY673OtherHFMG MA
FL115457000Medicaid