Provider Demographics
NPI:1407548712
Name:RYAN, TIMMON HAYLEY (PA-C)
Entity type:Individual
Prefix:
First Name:TIMMON
Middle Name:HAYLEY
Last Name:RYAN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:TIMMON
Other - Middle Name:HAYLEY
Other - Last Name:HERZBERG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:551 N HILLSIDE ST STE 320
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67214-4926
Mailing Address - Country:US
Mailing Address - Phone:316-685-1367
Mailing Address - Fax:
Practice Address - Street 1:9300 E 29TH ST N STE 206
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67226-2183
Practice Address - Country:US
Practice Address - Phone:316-685-1367
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-24
Last Update Date:2024-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS15-02803363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant