Basic Information
| Provider Information | |||||||||
| NPI: | 1215098025 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LITTLE | ||||||||
| FirstName: | RYAN | ||||||||
| MiddleName: | DANIEL | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 346 GRAND AVENUE | ||||||||
| Address2: | UNITED HEALTH SERVICES HOSP INC | ||||||||
| City: | JOHNSON CITY | ||||||||
| State: | NY | ||||||||
| PostalCode: | 13790 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6077298156 | ||||||||
| FaxNumber: | 6077293982 | ||||||||
| Practice Location | |||||||||
| Address1: | 33 MITCHELL AVE | ||||||||
| Address2: | SUITE 102 | ||||||||
| City: | BINGHAMTON | ||||||||
| State: | NY | ||||||||
| PostalCode: | 139031619 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6077623281 | ||||||||
| FaxNumber: | 6077623295 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/13/2006 | ||||||||
| LastUpdateDate: | 12/20/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | F335031 | NY | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 02805301 | 05 | NY | MEDICAID |