Provider Demographics
NPI:1487147013
Name:KENNEDY, RYAN MASARU (PA-C)
Entity type:Individual
Prefix:MR
First Name:RYAN
Middle Name:MASARU
Last Name:KENNEDY
Suffix:
Gender:M
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 1:18411 CLARK ST STE 302
Mailing Address - Street 2:
Mailing Address - City:TARZANA
Mailing Address - State:CA
Mailing Address - Zip Code:91356-3541
Mailing Address - Country:US
Mailing Address - Phone:818-501-7276
Mailing Address - Fax:
Practice Address - Street 1:4421 E HUENEME RD
Practice Address - Street 2:
Practice Address - City:OXNARD
Practice Address - State:CA
Practice Address - Zip Code:93033-8232
Practice Address - Country:US
Practice Address - Phone:805-469-4847
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-08
Last Update Date:2018-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA55631363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA55631OtherPHYSICIAN ASSISTANT BOARD