Basic Information
| Provider Information | |||||||||
| NPI: | 1396927760 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | RYAN | ||||||||
| FirstName: | KIM | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 269064 | ||||||||
| Address2: | |||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731269064 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4052313857 | ||||||||
| FaxNumber: | 4052727977 | ||||||||
| Practice Location | |||||||||
| Address1: | 6908 E RENO AVE | ||||||||
| Address2: | |||||||||
| City: | MIDWEST CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731102128 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4057377000 | ||||||||
| FaxNumber: | 4057377700 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/28/2007 | ||||||||
| LastUpdateDate: | 10/18/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/18/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 898 | OK | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.