Healthcare Provider Details

I. General information

NPI: 1417447277
Provider Name (Legal Business Name): RYAN CUERDON PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/16/2018
Last Update Date: 12/04/2024
Certification Date: 12/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

330 BROOKLINE AVE DEPT OF
BOSTON MA
02215-5491
US

IV. Provider business mailing address

330 BROOKLINE AVE DEPT OF
BOSTON MA
02215-5491
US

V. Phone/Fax

Practice location:
  • Phone: 617-667-3940
  • Fax: 617-667-2155
Mailing address:
  • Phone: 617-667-3940
  • Fax: 617-667-2155

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number1977
License Number StateNH
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA6535
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: