Basic Information
| Provider Information | |||||||||
| NPI: | 1922482009 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WILLIAMS | ||||||||
| FirstName: | RYLEY | ||||||||
| MiddleName: | SCOTT | ||||||||
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| Credential: | PA-C, ATC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 833 CHESTNUT ST STE 520 | ||||||||
| Address2: | |||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191074430 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6096777003 | ||||||||
| FaxNumber: | 2673393761 | ||||||||
| Practice Location | |||||||||
| Address1: | 255 N LAKEMONT AVE STE 207 | ||||||||
| Address2: | |||||||||
| City: | WINTER PARK | ||||||||
| State: | FL | ||||||||
| PostalCode: | 327923219 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8444074070 | ||||||||
| FaxNumber: | 4077433050 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/17/2015 | ||||||||
| LastUpdateDate: | 04/14/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/14/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2255A2300X | AL2688 | FL | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Specialist/Technologist | Athletic Trainer | 363A00000X | PAT9108971 | FL | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363AM0700X | PA9108971 | FL | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
ID Information
| ID | Type | State | Issuer | Description | PA9108971 | 01 | FL | MEDICAL LICENSE | OTHER | 015658500 | 05 | FL | MEDICAID |