Provider Demographics
NPI:1780410043
Name:DEMELLO, RYAN A
Entity type:Individual
Prefix:
First Name:RYAN
Middle Name:A
Last Name:DEMELLO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:151 SOUTHHALL LN STE 300
Mailing Address - Street 2:
Mailing Address - City:MAITLAND
Mailing Address - State:FL
Mailing Address - Zip Code:32751-7172
Mailing Address - Country:US
Mailing Address - Phone:866-400-3376
Mailing Address - Fax:407-650-3455
Practice Address - Street 1:2955 BROWNWOOD BLVD STE 204
Practice Address - Street 2:
Practice Address - City:THE VILLAGES
Practice Address - State:FL
Practice Address - Zip Code:32163-2040
Practice Address - Country:US
Practice Address - Phone:866-400-3376
Practice Address - Fax:352-877-3354
Is Sole Proprietor?:No
Enumeration Date:2024-09-12
Last Update Date:2025-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9119356363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant