Provider Demographics
NPI:1962182030
Name:SCHONEBOOM, RYAN JON
Entity type:Individual
Prefix:
First Name:RYAN
Middle Name:JON
Last Name:SCHONEBOOM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2525 W CENTURY BLVD APT 316
Mailing Address - Street 2:
Mailing Address - City:LODI
Mailing Address - State:CA
Mailing Address - Zip Code:95242-8012
Mailing Address - Country:US
Mailing Address - Phone:515-414-9172
Mailing Address - Fax:
Practice Address - Street 1:2525 W CENTURY BLVD APT 316
Practice Address - Street 2:
Practice Address - City:LODI
Practice Address - State:CA
Practice Address - Zip Code:95242-8012
Practice Address - Country:US
Practice Address - Phone:515-414-9172
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-24
Last Update Date:2025-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant