Provider Demographics
NPI:1174871933
Name:RYAN, MARILYSE ANN (PA-C)
Entity type:Individual
Prefix:
First Name:MARILYSE
Middle Name:ANN
Last Name:RYAN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:729 SUNRISE AVE
Mailing Address - Street 2:# 900
Mailing Address - City:ROSEVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95661-4565
Mailing Address - Country:US
Mailing Address - Phone:916-771-6539
Mailing Address - Fax:
Practice Address - Street 1:729 SUNRISE AVE
Practice Address - Street 2:# 900
Practice Address - City:ROSEVILLE
Practice Address - State:CA
Practice Address - Zip Code:95661-4565
Practice Address - Country:US
Practice Address - Phone:916-771-6539
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-08-27
Last Update Date:2022-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA22490363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical