Provider Demographics
NPI:1669150637
Name:RYAN, REBECCA MARIE (PA-C)
Entity type:Individual
Prefix:
First Name:REBECCA
Middle Name:MARIE
Last Name:RYAN
Suffix:
Gender:F
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 1:6907 VALENCIA CT
Mailing Address - Street 2:
Mailing Address - City:LEMON GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:91945-4280
Mailing Address - Country:US
Mailing Address - Phone:510-673-5683
Mailing Address - Fax:
Practice Address - Street 1:2017 1ST AVE STE 301
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92101-2033
Practice Address - Country:US
Practice Address - Phone:888-743-7526
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-10
Last Update Date:2023-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA62464363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant