1689756595 NPI number — DR. AMANDA D. RYAN DO

Table of content: DR. DAVID LI-KANG CHEN M.D. (NPI 1922364611)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1689756595 NPI number — DR. AMANDA D. RYAN DO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
RYAN
Provider First Name:
AMANDA
Provider Middle Name:
D.
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
DO
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
RHODES
Provider Other First Name:
AMANDA
Provider Other Middle Name:
D.
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
D.O.
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1689756595
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/27/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2420 W PIERCE ST
Provider Second Line Business Mailing Address:
SUITE 100
Provider Business Mailing Address City Name:
CARLSBAD
Provider Business Mailing Address State Name:
NM
Provider Business Mailing Address Postal Code:
88220-3543
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
575-234-1855
Provider Business Mailing Address Fax Number:
575-234-2854

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2420 W PIERCE ST
Provider Second Line Business Practice Location Address:
SUITE 100
Provider Business Practice Location Address City Name:
CARLSBAD
Provider Business Practice Location Address State Name:
NM
Provider Business Practice Location Address Postal Code:
88220-3543
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
575-234-1855
Provider Business Practice Location Address Fax Number:
575-234-2854
Provider Enumeration Date:
10/19/2006

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: 207RI0011X , with the licence number:  A-1931-16 , registered in the state of NM ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207RC0000X , with the licence number: OC10503 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 78306 . This is a "BCBS" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 000430500 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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