Provider Demographics
NPI:1306811567
Name:WILSON, RYAN M (PA)
Entity type:Individual
Prefix:
First Name:RYAN
Middle Name:M
Last Name:WILSON
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3300 S FISKE BLVD
Mailing Address - Street 2:
Mailing Address - City:ROCKLEDGE
Mailing Address - State:FL
Mailing Address - Zip Code:32955-4306
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1350 HICKORY ST
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32901-3224
Practice Address - Country:US
Practice Address - Phone:321-434-1401
Practice Address - Fax:321-434-1667
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-21
Last Update Date:2023-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLP9102044363A00000X
FLPA9102044363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLE8442UOtherFL MEDICARE
FLP00466915OtherRR MEDICARE
FL291346100Medicaid
FLP00466915OtherRR MEDICARE
P73431Medicare UPIN