Provider Demographics
NPI:1821599143
Name:SEIDL, RYAN WAYNE (PA-C)
Entity type:Individual
Prefix:
First Name:RYAN
Middle Name:WAYNE
Last Name:SEIDL
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:RYAN
Other - Middle Name:WAYNE
Other - Last Name:FRY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:AGE WELL LLC
Mailing Address - Street 2:468 OLD CHEROKEE ROAD
Mailing Address - City:LEXINGTON
Mailing Address - State:SC
Mailing Address - Zip Code:29072
Mailing Address - Country:US
Mailing Address - Phone:803-970-6972
Mailing Address - Fax:839-218-5344
Practice Address - Street 1:468 OLD CHEROKEE RD
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:SC
Practice Address - Zip Code:29072-9031
Practice Address - Country:US
Practice Address - Phone:803-970-6972
Practice Address - Fax:839-218-5344
Is Sole Proprietor?:No
Enumeration Date:2018-02-22
Last Update Date:2025-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC2852363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC3540PAMedicaid