Basic Information
| Provider Information | |||||||||
| NPI: | 1053747493 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RYAN | ||||||||
| FirstName: | KENNETH | ||||||||
| MiddleName: | C | ||||||||
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| Credential: | APRN | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 41113 | ||||||||
| Address2: | |||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322031113 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9043764400 | ||||||||
| FaxNumber: | 9043915595 | ||||||||
| Practice Location | |||||||||
| Address1: | 1370 13TH AVE S STE 215 | ||||||||
| Address2: | |||||||||
| City: | JACKSONVILLE BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322503206 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9042491041 | ||||||||
| FaxNumber: | 9042499764 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/17/2013 | ||||||||
| LastUpdateDate: | 02/12/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | APRN9367359 | FL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
No ID Information.