Basic Information
| Provider Information | |||||||||
| NPI: | 1831493196 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | RYAN | ||||||||
| FirstName: | JAMES | ||||||||
| MiddleName: | LEE | ||||||||
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| Credential: | FNP-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 550 | ||||||||
| Address2: | |||||||||
| City: | VANCEBURG | ||||||||
| State: | KY | ||||||||
| PostalCode: | 411790550 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6067963029 | ||||||||
| FaxNumber: | 6067966221 | ||||||||
| Practice Location | |||||||||
| Address1: | 142 DEPOT DRIVE | ||||||||
| Address2: | |||||||||
| City: | SOUTH SHORE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 41175 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6069322271 | ||||||||
| FaxNumber: | 6069322273 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/30/2010 | ||||||||
| LastUpdateDate: | 12/06/2011 | ||||||||
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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 | 363LF0000X | 6463P | KY | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363LF0000X | 3006463 | KY | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 7100149730 | 05 | KY | MEDICAID | 3124096 | 05 | OH | MEDICAID |