Healthcare Provider Details

I. General information

NPI: 1386345932
Provider Name (Legal Business Name): RYAN KERRY CHIN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/10/2023
Last Update Date: 03/12/2026
Certification Date: 03/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

467 VISTA AVE
PAGE AZ
86040-1478
US

IV. Provider business mailing address

PO BOX 1625
PAGE AZ
86040-1625
US

V. Phone/Fax

Practice location:
  • Phone: 928-645-8123
  • Fax:
Mailing address:
  • Phone: 928-645-8123
  • Fax: 928-645-3832

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number11435
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: