Provider Demographics
NPI:1952902058
Name:TAYLOR, RYAN PAUL
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:PAUL
Last Name:TAYLOR
Suffix:
Gender:M
Credentials:
Other - Prefix:MR
Other - First Name:RYAN
Other - Middle Name:P
Other - Last Name:TAYLOR
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PA-S
Mailing Address - Street 1:2623 YORBA LINDA BLVD APT 222
Mailing Address - Street 2:
Mailing Address - City:FULLERTON
Mailing Address - State:CA
Mailing Address - Zip Code:92831-1613
Mailing Address - Country:US
Mailing Address - Phone:619-370-0042
Mailing Address - Fax:
Practice Address - Street 1:1630 E HERNDON AVE
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93720-3391
Practice Address - Country:US
Practice Address - Phone:559-256-5200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-04
Last Update Date:2022-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CA60550363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program