MEDICARE: SUSAN M RYAN PA-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363AM0700X	Medical Physician Assistant	PA9101850	FL

General Provider Information

NPI Number	:	1528095718
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SUSAN M RYAN PA-C

Provider Business Mailing Address
First Line	:	1349 S INTERNATIONAL PKWY
Second Line	:	SUITE 1411
City	:	LAKE MARY
State	:	FL
Zip	:	32746-1697
Country	:	US
Telephone Number	:	407-333-3360
Fax Number	:	407-333-2920

Provider Business Practice Location Address
First Line	:	1349 SOUTH INTERNATIONAL PARKWAY
Second Line	:	SUITE 1411
City	:	LAKE MARY
State	:	FL
Zip	:	32746
Country	:	US
Telephone Number	:	407-333-3360
Fax Number	:	407-333-2920

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/26/2006
Last Update Date	:	02/17/2009

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