1558844902 NPI number — JORDAN RYBA PHYSICIAN ASSISTANT

Table of content: JORDAN RYBA PHYSICIAN ASSISTANT (NPI 1558844902)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1558844902 NPI number — JORDAN RYBA PHYSICIAN ASSISTANT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
RYBA
Provider First Name:
JORDAN
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PHYSICIAN ASSISTANT
Provider Gender Code:
F

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:
1558844902
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/05/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2454 BRIARMOOR RD NE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ATLANTA
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30345-2112
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
770-630-5341
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3515 CAMP CREEK PKWY STE 110
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
EAST POINT
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30344-8411
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
43-447-3374
Provider Business Practice Location Address Fax Number:
404-344-8338
Provider Enumeration Date:
09/12/2018

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 , with the licence number:  8951 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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