Provider Demographics
NPI:1932452091
Name:BLACK, RYAN (PA-C)
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:
Last Name:BLACK
Suffix:
Gender:M
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 1:703 RIGBY LAKE DR
Mailing Address - Street 2:
Mailing Address - City:RIGBY
Mailing Address - State:ID
Mailing Address - Zip Code:83442-5192
Mailing Address - Country:US
Mailing Address - Phone:208-745-0200
Mailing Address - Fax:208-745-0212
Practice Address - Street 1:703 RIGBY LAKE DR
Practice Address - Street 2:
Practice Address - City:RIGBY
Practice Address - State:ID
Practice Address - Zip Code:83442-5192
Practice Address - Country:US
Practice Address - Phone:208-745-0200
Practice Address - Fax:208-745-0212
Is Sole Proprietor?:No
Enumeration Date:2012-10-25
Last Update Date:2023-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant