Healthcare Provider Details

I. General information

NPI: 1306291877
Provider Name (Legal Business Name): RYAN MARK RISTER DO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/03/2016
Last Update Date: 07/02/2020
Certification Date: 07/02/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1226 DANTIGNAC ST
AUGUSTA GA
30901-2788
US

IV. Provider business mailing address

PO BOX 2344
AUGUSTA GA
30903-2344
US

V. Phone/Fax

Practice location:
  • Phone: 706-922-0600
  • Fax: 706-922-0604
Mailing address:
  • Phone: 706-922-0600
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number86270
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberR6885
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: