1114310182 NPI number — KATHERINE MARY RYAN L.D.O.

Table of content: KATHERINE MARY RYAN L.D.O. (NPI 1114310182)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114310182 NPI number — KATHERINE MARY RYAN L.D.O.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
RYAN
Provider First Name:
KATHERINE
Provider Middle Name:
MARY
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
L.D.O.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
MAY
Provider Other First Name:
KATHERINE
Provider Other Middle Name:
MARY
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
L.D.O.
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1114310182
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/13/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
351 ORONDO AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WENATCHEE
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98801-2826
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
509-662-4747
Provider Business Mailing Address Fax Number:
509-663-5338

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
351 ORONDO AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WENATCHEE
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98801-2826
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
509-662-4747
Provider Business Practice Location Address Fax Number:
509-663-5338
Provider Enumeration Date:
03/13/2015

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: 156FX1800X , with the licence number:  DO 00000833 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1000288 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".




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