Provider Demographics
NPI:1528095718
Name:RYAN, SUSAN M (PA-C)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:M
Last Name:RYAN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1349 S INTERNATIONAL PKWY
Mailing Address - Street 2:SUITE 1411
Mailing Address - City:LAKE MARY
Mailing Address - State:FL
Mailing Address - Zip Code:32746-1697
Mailing Address - Country:US
Mailing Address - Phone:407-333-3360
Mailing Address - Fax:407-333-2920
Practice Address - Street 1:1349 SOUTH INTERNATIONAL PARKWAY
Practice Address - Street 2:SUITE 1411
Practice Address - City:LAKE MARY
Practice Address - State:FL
Practice Address - Zip Code:32746
Practice Address - Country:US
Practice Address - Phone:407-333-3360
Practice Address - Fax:407-333-2920
Is Sole Proprietor?:No
Enumeration Date:2006-06-26
Last Update Date:2009-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9101850363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLE77474Medicare ID - Type UnspecifiedMEDICARE