Basic Information
| Provider Information | |||||||||
| NPI: | 1073045597 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BURKHOLDER | ||||||||
| FirstName: | RYAN | ||||||||
| MiddleName: | M. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1501 KINGS HWY | ||||||||
| Address2: | INTERNAL MEDICINE | ||||||||
| City: | SHREVEPORT | ||||||||
| State: | LA | ||||||||
| PostalCode: | 711034228 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3186260434 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1501 KINGS HWY | ||||||||
| Address2: | INTERNAL MEDICINE | ||||||||
| City: | SHREVEPORT | ||||||||
| State: | LA | ||||||||
| PostalCode: | 711034228 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3186260434 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/03/2017 | ||||||||
| LastUpdateDate: | 02/08/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 02/08/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208M00000X | 35.13911 | OH | N | Allopathic & Osteopathic Physicians | Hospitalist | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 207P00000X | 312696 | LA | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
No ID Information.