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General NPI Number Information
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NPI Number | 1972375079
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Entity Type | Individual
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Provider Name | RYAN BLACK PA-C
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Gender | Male
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Dates
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Enumeration Date | 10/23/2023
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Last Update Date | 10/30/2024
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Provider Practice Location Address
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Address Line | 802 MAGNOLIA AVE STE 205
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City | CORONA
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State | CA
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Zip | 92879-3144
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Country | US
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Telephone | 951-281-2730
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Fax |
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Provider Business Mailing Address
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Address Line | 40335 WINCHESTER RD SUITE E #238
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City | TEMECULA
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State | CA
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Zip | 92591
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Country | US
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Telephone | 760-420-4123
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363AM0700X
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Taxonomy Name | Medical Physician Assistant
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License Number | PA63384
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License Number State | CA
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