1114736964 NPI number — JENARO ADAM RYAN PHYSICIAN ASSISTANT

Table of content: JENARO ADAM RYAN PHYSICIAN ASSISTANT (NPI 1114736964)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114736964 NPI number — JENARO ADAM RYAN PHYSICIAN ASSISTANT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
RYAN
Provider First Name:
JENARO
Provider Middle Name:
ADAM
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PHYSICIAN ASSISTANT
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1114736964
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/06/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 5105
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BELFAST
Provider Business Mailing Address State Name:
ME
Provider Business Mailing Address Postal Code:
04915-5100
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
910-332-3800
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3714 GUARDIAN AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MOREHEAD CITY
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28557-2974
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
910-332-3800
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/06/2025

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363A00000X , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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