Healthcare Provider Details

I. General information

NPI: 1780773341
Provider Name (Legal Business Name): KAROLYN RYAN PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/12/2006
Last Update Date: 03/25/2021
Certification Date: 03/25/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4545 HERITAGE TRACE PKWY STE 1500
FORT WORTH TX
76244-8938
US

IV. Provider business mailing address

4545 HERITAGE TRACE PKWY STE 1500
FORT WORTH TX
76244-8938
US

V. Phone/Fax

Practice location:
  • Phone: 817-337-6604
  • Fax: 817-337-6866
Mailing address:
  • Phone: 817-337-6604
  • Fax: 817-337-6866

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA10231
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA9104967
License Number StateFL
# 3
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number010467
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: