Healthcare Provider Details

I. General information

NPI: 1679490015
Provider Name (Legal Business Name): RYAN STUART HOGUE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/06/2026
Last Update Date: 07/06/2026
Certification Date: 07/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

765 S TRUSS AVE
MERIDIAN ID
83642-3571
US

IV. Provider business mailing address

765 S TRUSS AVE
MERIDIAN ID
83642-3571
US

V. Phone/Fax

Practice location:
  • Phone: 503-593-1372
  • Fax:
Mailing address:
  • Phone: 503-593-1372
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number63716
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: