Provider Demographics
NPI:1700289238
Name:CONNOLLY, RYAN (PA)
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:
Last Name:CONNOLLY
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:6620 FLY RD
Mailing Address - Street 2:STE 200
Mailing Address - City:EAST SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13057-9791
Mailing Address - Country:US
Mailing Address - Phone:315-464-4472
Mailing Address - Fax:315-464-5229
Practice Address - Street 1:6620 FLY RD
Practice Address - Street 2:STE 200
Practice Address - City:EAST SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13057-9791
Practice Address - Country:US
Practice Address - Phone:315-464-4472
Practice Address - Fax:315-464-5229
Is Sole Proprietor?:No
Enumeration Date:2014-09-29
Last Update Date:2014-09-29
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY018048363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical