Basic Information
| Provider Information | |||||||||
| NPI: | 1639167695 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | RYAN | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | EDWARD | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1500 E 2ND ST | ||||||||
| Address2: | SUITE 206 | ||||||||
| City: | RENO | ||||||||
| State: | NV | ||||||||
| PostalCode: | 895021181 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7757897000 | ||||||||
| FaxNumber: | 7757897040 | ||||||||
| Practice Location | |||||||||
| Address1: | 1500 E 2ND ST | ||||||||
| Address2: | SUITE 206 | ||||||||
| City: | RENO | ||||||||
| State: | NV | ||||||||
| PostalCode: | 895021181 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7757897000 | ||||||||
| FaxNumber: | 7757897040 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/12/2005 | ||||||||
| 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 | 208600000X | 5019 | NV | X | Allopathic & Osteopathic Physicians | Surgery | 2086S0129X | 5019 | NV | X | Allopathic & Osteopathic Physicians | Surgery | Vascular Surgery |
ID Information
| ID | Type | State | Issuer | Description | CC5339 | 01 | BCBS | OTHER | XPY039070 | 05 | CA | MEDICAID |