Healthcare Provider Details

I. General information

NPI: 1285271908
Provider Name (Legal Business Name): PATRICK GERARD RYAN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/01/2019
Last Update Date: 12/01/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 CARLYLE DR # 6A-SOUTH
CLIFFSIDE PARK NJ
07010-3501
US

IV. Provider business mailing address

100 CARLYLE DR # 6A-SOUTH
CLIFFSIDE PARK NJ
07010-3501
US

V. Phone/Fax

Practice location:
  • Phone: 646-413-1956
  • Fax:
Mailing address:
  • Phone: 646-413-1956
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number307714
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: