Provider Demographics
NPI:1548632581
Name:DAVIS, RYAN (PA)
Entity type:Individual
Prefix:
First Name:RYAN
Middle Name:
Last Name:DAVIS
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 1:225 BRIDGE ST
Mailing Address - Street 2:
Mailing Address - City:GROTON
Mailing Address - State:CT
Mailing Address - Zip Code:06340-3710
Mailing Address - Country:US
Mailing Address - Phone:860-917-8031
Mailing Address - Fax:
Practice Address - Street 1:50 WASON AVE FL 2
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MA
Practice Address - Zip Code:01107-1280
Practice Address - Country:US
Practice Address - Phone:413-794-1800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-10-29
Last Update Date:2025-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAPA101950363AS0400X
CT3466363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004002358Medicaid
CT004002358Medicaid