Provider Demographics
NPI:1215316419
Name:DEDEAUX, RYAN M (PA)
Entity type:Individual
Prefix:
First Name:RYAN
Middle Name:M
Last Name:DEDEAUX
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 2699
Mailing Address - Street 2:ATTN: SHMG/HPE
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32513-2699
Mailing Address - Country:US
Mailing Address - Phone:850-494-9000
Mailing Address - Fax:850-474-4123
Practice Address - Street 1:4541 N DAVIS HWY STE A
Practice Address - Street 2:
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32503-2733
Practice Address - Country:US
Practice Address - Phone:850-494-9000
Practice Address - Fax:850-474-4123
Is Sole Proprietor?:No
Enumeration Date:2015-05-21
Last Update Date:2015-09-01
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FLPA9108886363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant