Basic Information
| Provider Information | |||||||||
| NPI: | 1710330113 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | RYAN | ||||||||
| FirstName: | LUNDEN | ||||||||
| MiddleName: | LISTON | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 9196 | ||||||||
| Address2: | |||||||||
| City: | MORGANTOWN | ||||||||
| State: | WV | ||||||||
| PostalCode: | 265069196 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3042931168 | ||||||||
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| Practice Location | |||||||||
| Address1: | 612 WASHINGTON BLVD | ||||||||
| Address2: | |||||||||
| City: | BELPRE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 457142465 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3044858040 | ||||||||
| FaxNumber: | 3044854883 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/20/2016 | ||||||||
| LastUpdateDate: | 10/31/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/31/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207XX0801X | 35.146094 | OH | N | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Orthopaedic Trauma | 207XX0801X | 28383 | WV | N | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Orthopaedic Trauma | 390200000X | WV | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 207X00000X | TP213 | KY | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
ID Information
| ID | Type | State | Issuer | Description | 1710330113 | 05 | WV | MEDICAID |