Basic Information
| Provider Information | |||||||||
| NPI: | 1225613797 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | TETLA | ||||||||
| FirstName: | RYAN | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 697 LOUISIANA RD | ||||||||
| Address2: | |||||||||
| City: | DYESS AFB | ||||||||
| State: | TX | ||||||||
| PostalCode: | 796071141 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 697 LOUISIANA RD | ||||||||
| Address2: | |||||||||
| City: | DYESS AFB | ||||||||
| State: | TX | ||||||||
| PostalCode: | 796071141 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3522650111 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/16/2021 | ||||||||
| LastUpdateDate: | 07/25/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/25/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208D00000X | ME158021 | FL | Y | Allopathic & Osteopathic Physicians | General Practice |
No ID Information.