Basic Information
| Provider Information | |||||||||
| NPI: | 1760081962 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | RYAN | ||||||||
| FirstName: | THOMAS | ||||||||
| MiddleName: | P | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2003 KOOTENAI HEALTH WAY | ||||||||
| Address2: | |||||||||
| City: | COEUR D ALENE | ||||||||
| State: | ID | ||||||||
| PostalCode: | 838146051 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2086253555 | ||||||||
| FaxNumber: | 2087651494 | ||||||||
| Practice Location | |||||||||
| Address1: | 700 W IRONWOOD DR STE 378 | ||||||||
| Address2: | |||||||||
| City: | COEUR D ALENE | ||||||||
| State: | ID | ||||||||
| PostalCode: | 838144401 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2086253555 | ||||||||
| FaxNumber: | 2086251494 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/20/2020 | ||||||||
| LastUpdateDate: | 10/07/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/07/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LA2100X | 96119 | TX | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Acute Care | 363L00000X | NP69133 | ID | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 7161988 | 01 | TN | DOB | OTHER |