Provider Demographics
NPI:1124257803
Name:RYAN, AUBREY (PA)
Entity type:Individual
Prefix:
First Name:AUBREY
Middle Name:
Last Name:RYAN
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:AUBREY
Other - Middle Name:
Other - Last Name:STIMOLA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:1 HOSPITAL RD
Mailing Address - Street 2:
Mailing Address - City:OAK BLUFFS
Mailing Address - State:MA
Mailing Address - Zip Code:02557-1406
Mailing Address - Country:US
Mailing Address - Phone:508-693-0410
Mailing Address - Fax:508-693-5971
Practice Address - Street 1:1 HOSPITAL RD
Practice Address - Street 2:
Practice Address - City:OAK BLUFFS
Practice Address - State:MA
Practice Address - Zip Code:02557-1406
Practice Address - Country:US
Practice Address - Phone:508-693-0410
Practice Address - Fax:508-693-5971
Is Sole Proprietor?:No
Enumeration Date:2009-07-02
Last Update Date:2021-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY013352363A00000X
MAPA7906363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03156663Medicaid
NYJ400005440Medicare PIN
NY03156663Medicaid