Basic Information
| Provider Information | |||||||||
| NPI: | 1407847833 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ANDERSON | ||||||||
| FirstName: | RYAN | ||||||||
| MiddleName: | W | ||||||||
| NamePrefix: | |||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 401 6TH AVE | ||||||||
| Address2: | |||||||||
| City: | MONTGOMERY | ||||||||
| State: | WV | ||||||||
| PostalCode: | 251362116 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3044425151 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 3701 MACCORKLE AVE SE | ||||||||
| Address2: | |||||||||
| City: | CHARLESTON | ||||||||
| State: | WV | ||||||||
| PostalCode: | 253041525 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3044425151 | ||||||||
| FaxNumber: | 3044427494 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/03/2005 | ||||||||
| LastUpdateDate: | 12/13/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 12/13/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | 01148 | WV | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
ID Information
| ID | Type | State | Issuer | Description | 374 | 01 | WV | WV BD. OSTEO LICENSE | OTHER | 01148 | 01 | WV | STATE LICENSE NUMBER | OTHER |