Basic Information
| Provider Information | |||||||||
| NPI: | 1790731032 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | RYAN | ||||||||
| FirstName: | J. THOMAS | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2300 FALL HILL AVE | ||||||||
| Address2: | SUITE 215 | ||||||||
| City: | FREDERICKSBURG | ||||||||
| State: | VA | ||||||||
| PostalCode: | 224013342 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5403745097 | ||||||||
| FaxNumber: | 5403740378 | ||||||||
| Practice Location | |||||||||
| Address1: | 120 EXECUTIVE CENTER PKWY | ||||||||
| Address2: | |||||||||
| City: | FREDERICKSBURG | ||||||||
| State: | VA | ||||||||
| PostalCode: | 224013100 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5403745200 | ||||||||
| FaxNumber: | 5403741164 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/26/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 0101024132 | VA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 5632862 | 05 | VA | MEDICAID |