Healthcare Provider Details

I. General information

NPI: 1619276789
Provider Name (Legal Business Name): RYAN MICHELLE DADDS PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/15/2011
Last Update Date: 08/21/2020
Certification Date: 08/21/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1223 GATEWAY DR 1E
MELBOURNE FL
32901
US

IV. Provider business mailing address

3300 S FISKE BLVD
ROCKLEDGE FL
32955-4306
US

V. Phone/Fax

Practice location:
  • Phone: 321-725-4505
  • Fax: 321-409-8932
Mailing address:
  • Phone: 321-725-4505
  • Fax: 321-434-1981

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberPA9109222
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA9109222
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: