Basic Information
| Provider Information | |||||||||
| NPI: | 1518395854 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RYAN | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | KATHERINE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | NP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | VERDIN | ||||||||
| OtherFirstName: | MARY | ||||||||
| OtherMiddleName: | |||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1800 HOWELL MILL RD NW STE 800 | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303180922 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4043509853 | ||||||||
| FaxNumber: | 4044771162 | ||||||||
| Practice Location | |||||||||
| Address1: | 775 POPLAR RD STE 310 | ||||||||
| Address2: | |||||||||
| City: | NEWNAN | ||||||||
| State: | GA | ||||||||
| PostalCode: | 302658303 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7702512590 | ||||||||
| FaxNumber: | 4044771162 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/24/2013 | ||||||||
| LastUpdateDate: | 04/14/2020 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 04/14/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 272967 | NC | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363LA2200X | COA.15224-NP | OH | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health | 363LA2200X | RN248115 | GA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health |
ID Information
| ID | Type | State | Issuer | Description | 5007170 | 01 | NC | NCBON | OTHER | COA.15224-NP | 01 | OH | CNP | OTHER |