Healthcare Provider Details

I. General information

NPI: 1457566606
Provider Name (Legal Business Name): RYAN JOSEPH CLANCY PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/11/2007
Last Update Date: 03/23/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

120 S 30TH ST 2ND FLOOR
PHILADELPHIA PA
19104-3403
US

IV. Provider business mailing address

1412 FAIRMOUNT AVENUE
PHILADELPHIA PA
19130
US

V. Phone/Fax

Practice location:
  • Phone: 215-222-2466
  • Fax: 215-222-2462
Mailing address:
  • Phone: 215-599-4851
  • Fax: 215-232-4093

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberMA051812
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: