1265449060 NPI number — DR. LUCY HABERTHIER-RYAN MD

Table of content: DR. LUCY HABERTHIER-RYAN MD (NPI 1265449060)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1265449060 NPI number — DR. LUCY HABERTHIER-RYAN MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HABERTHIER-RYAN
Provider First Name:
LUCY
Provider Middle Name:
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1265449060
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/23/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1359
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ROCK SPRINGS
Provider Business Mailing Address State Name:
WY
Provider Business Mailing Address Postal Code:
82902-1359
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
307-212-7717
Provider Business Mailing Address Fax Number:
307-212-7513

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1180 COLLEGE DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ROCK SPRINGS
Provider Business Practice Location Address State Name:
WY
Provider Business Practice Location Address Postal Code:
82901-5863
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
307-212-7717
Provider Business Practice Location Address Fax Number:
307-212-7513
Provider Enumeration Date:
08/02/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 208000000X , with the licence number:  J5094 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208000000X , with the licence number: 12406A , registered in the state of WY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 0020ED . This is a "BLUECROSS/BLUESHIELD" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 130812404 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 10020015 . This is a "AMERIGROUP" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 5695001 . This is a "AETNA" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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