1912264201 NPI number — DR. AUDRA JACQUELINE RYAN-SHEPARD M.D.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1912264201 NPI number — DR. AUDRA JACQUELINE RYAN-SHEPARD M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
RYAN-SHEPARD
Provider First Name:
AUDRA
Provider Middle Name:
JACQUELINE
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
RYAN
Provider Other First Name:
AUDRA
Provider Other Middle Name:
JACQUELINE
Provider Other Name Prefix Text:
DR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
MD
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1912264201
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/30/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
300 HIGH ST FL 4
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HAMILTON
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
45011-6078
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
513-454-1460
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
300 FOREST AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DAYTON
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
45405-4500
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
513-454-1111
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/12/2012

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: 2084P0800X , with the licence number:  35.135902 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 390200000X , with the licence number: 63251 ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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