Healthcare Provider Details

I. General information

NPI: 1689087140
Provider Name (Legal Business Name): RYAN MAZZONE PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/03/2014
Last Update Date: 05/10/2022
Certification Date: 05/10/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6600 W BROAD ST STE 300
RICHMOND VA
23230
US

IV. Provider business mailing address

1000 BOULDERS PKWY STE 102
NORTH CHESTERFIELD VA
23225-5515
US

V. Phone/Fax

Practice location:
  • Phone: 804-320-4243
  • Fax: 804-622-0552
Mailing address:
  • Phone: 804-320-4243
  • Fax: 804-622-0552

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: