Provider Demographics
NPI:1740717446
Name:DODGE, RYAN (PA)
Entity type:Individual
Prefix:
First Name:RYAN
Middle Name:
Last Name:DODGE
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15 HOSPITAL DR
Mailing Address - Street 2:
Mailing Address - City:YORK
Mailing Address - State:ME
Mailing Address - Zip Code:03909-1011
Mailing Address - Country:US
Mailing Address - Phone:207-351-2478
Mailing Address - Fax:207-351-2216
Practice Address - Street 1:343 US ROUTE 1
Practice Address - Street 2:
Practice Address - City:YORK
Practice Address - State:ME
Practice Address - Zip Code:03909-1636
Practice Address - Country:US
Practice Address - Phone:207-351-2600
Practice Address - Fax:207-351-2601
Is Sole Proprietor?:No
Enumeration Date:2017-05-12
Last Update Date:2017-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPA11111363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant