Provider Demographics
NPI:1881970572
Name:BURDICK, RYAN (FNP)
Entity type:Individual
Prefix:
First Name:RYAN
Middle Name:
Last Name:BURDICK
Suffix:
Gender:M
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:143 N CLARK ST STE B
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93701-2182
Mailing Address - Country:US
Mailing Address - Phone:559-233-0335
Mailing Address - Fax:559-233-0315
Practice Address - Street 1:143 N CLARK ST STE B
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93701-2182
Practice Address - Country:US
Practice Address - Phone:559-233-0335
Practice Address - Fax:559-233-0315
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-26
Last Update Date:2013-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA21122363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0043790Medicaid
CAGR0043790Medicaid