Provider Demographics
NPI:1972375079
Name:BLACK, RYAN (PA-C)
Entity type:Individual
Prefix:MR
First Name:RYAN
Middle Name:
Last Name:BLACK
Suffix:
Gender:M
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 1:40335 WINCHESTER RD
Mailing Address - Street 2:SUITE E #238
Mailing Address - City:TEMECULA
Mailing Address - State:CA
Mailing Address - Zip Code:92591
Mailing Address - Country:US
Mailing Address - Phone:760-420-4123
Mailing Address - Fax:
Practice Address - Street 1:802 MAGNOLIA AVE STE 205
Practice Address - Street 2:
Practice Address - City:CORONA
Practice Address - State:CA
Practice Address - Zip Code:92879-3144
Practice Address - Country:US
Practice Address - Phone:951-281-2730
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-10-23
Last Update Date:2024-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA63384363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical