Healthcare Provider Details

I. General information

NPI: 1780242032
Provider Name (Legal Business Name): RYAN T LAHEY PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/02/2019
Last Update Date: 10/01/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1602 AYLWARD AVE
ELLSWORTH KS
67439-2541
US

IV. Provider business mailing address

1602 AYLWARD AVE
ELLSWORTH KS
67439-2541
US

V. Phone/Fax

Practice location:
  • Phone: 785-472-5029
  • Fax: 785-472-5731
Mailing address:
  • Phone: 785-472-5029
  • Fax: 785-472-5731

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number1502245
License Number StateKS
# 2
Primary TaxonomyN
Taxonomy Code146N00000X
TaxonomyBasic Emergency Medical Technician
License Number50869
License Number StateKS
# 3
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: