Healthcare Provider Details

I. General information

NPI: 1750115317
Provider Name (Legal Business Name): TYLER DEAN RYAN PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/27/2024
Last Update Date: 09/11/2024
Certification Date: 09/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1120 W LA VETA AVE STE 300
ORANGE CA
92868-4246
US

IV. Provider business mailing address

2232 SYCAMORE AVE
TUSTIN CA
92780-6750
US

V. Phone/Fax

Practice location:
  • Phone: 714-598-1745
  • Fax:
Mailing address:
  • Phone: 714-376-2047
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: