Healthcare Provider Details

I. General information

NPI: 1306396676
Provider Name (Legal Business Name): MITCHELL RYAN CAGLE NP-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/10/2016
Last Update Date: 10/10/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 TOWNCENTER BLVD
TUSCALOOSA AL
35406-1833
US

IV. Provider business mailing address

4427 OXFORD GATE DR
TUSCALOOSA AL
35405-4768
US

V. Phone/Fax

Practice location:
  • Phone: 205-462-3334
  • Fax:
Mailing address:
  • Phone: 205-294-1819
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number1-124207
License Number StateAL
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberF08161087
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: