Basic Information
| Provider Information | |||||||||
| NPI: | 1740673920 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MOELLENKAMP | ||||||||
| FirstName: | RYAN | ||||||||
| MiddleName: | CHRIS | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 90 VERMONT AVE STE 300 | ||||||||
| Address2: | |||||||||
| City: | OAK RIDGE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 378306478 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8654812541 | ||||||||
| FaxNumber: | 8654838151 | ||||||||
| Practice Location | |||||||||
| Address1: | 90 VERMONT AVE STE 300 | ||||||||
| Address2: | |||||||||
| City: | OAK RIDGE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 378306478 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8654812541 | ||||||||
| FaxNumber: | 8654838151 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/11/2015 | ||||||||
| LastUpdateDate: | 07/03/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AS0400X | 2928 | TN | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical | 363A00000X | 2928 | TN | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363A00000X | 0010-05615 | NC | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.