Provider Demographics
NPI:1457357956
Name:RYAN, JACLYN A (PA-C)
Entity Type:Individual
Prefix:MS
First Name:JACLYN
Middle Name:A
Last Name:RYAN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MS
Other - First Name:JACLYN
Other - Middle Name:A
Other - Last Name:BURNS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:9 WASHINGTON AVE FL 1A
Mailing Address - Street 2:
Mailing Address - City:HAMDEN
Mailing Address - State:CT
Mailing Address - Zip Code:06518-3267
Mailing Address - Country:US
Mailing Address - Phone:203-865-6784
Mailing Address - Fax:203-865-6788
Practice Address - Street 1:9 WASHINGTON AVE FL 1A
Practice Address - Street 2:
Practice Address - City:HAMDEN
Practice Address - State:CT
Practice Address - Zip Code:06518-3267
Practice Address - Country:US
Practice Address - Phone:203-865-6784
Practice Address - Fax:203-865-6788
Is Sole Proprietor?:No
Enumeration Date:2005-06-21
Last Update Date:2021-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000433363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTR97542Medicare UPIN
CT970000229Medicare ID - Type Unspecified