Healthcare Provider Details

I. General information

NPI: 1285228213
Provider Name (Legal Business Name): RYAN HARRIS FNP-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/20/2021
Last Update Date: 07/19/2021
Certification Date: 07/19/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1055 BOWLES AVE STE 202
FENTON MO
63026-2308
US

IV. Provider business mailing address

1055 BOWLES AVE STE 202
FENTON MO
63026-2308
US

V. Phone/Fax

Practice location:
  • Phone: 636-326-7821
  • Fax: 636-326-7897
Mailing address:
  • Phone: 636-326-7821
  • Fax: 636-326-7897

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN60944314
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number041500644
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number2013025076
License Number StateMO
# 4
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209022160
License Number StateIL
# 5
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number2020018086
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: