Basic Information
| Provider Information | |||||||||
| NPI: | 1497923288 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MIYAMOTO | ||||||||
| FirstName: | RYAN | ||||||||
| MiddleName: | GLENN | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1860 TOWN CENTER DR STE 300 | ||||||||
| Address2: | |||||||||
| City: | RESTON | ||||||||
| State: | VA | ||||||||
| PostalCode: | 201905900 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7034356604 | ||||||||
| FaxNumber: | 7036624506 | ||||||||
| Practice Location | |||||||||
| Address1: | 3620 JOSEPH SIEWICK DR STE 201 | ||||||||
| Address2: | |||||||||
| City: | FAIRFAX | ||||||||
| State: | VA | ||||||||
| PostalCode: | 220331758 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7033910111 | ||||||||
| FaxNumber: | 7033912945 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/14/2008 | ||||||||
| LastUpdateDate: | 01/12/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/12/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207XX0005X | 0101245582 | VA | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Sports Medicine |
No ID Information.