Healthcare Provider Details

I. General information

NPI: 1205822434
Provider Name (Legal Business Name): AMY RYAN M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/22/2005
Last Update Date: 10/28/2020
Certification Date: 09/06/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2600 E 7TH ST SUITE 100
CHARLOTTE NC
28204-4375
US

IV. Provider business mailing address

1900 RANDOLPH RD SUITE 500
CHARLOTTE NC
28207-1122
US

V. Phone/Fax

Practice location:
  • Phone: 704-384-8800
  • Fax: 704-384-8819
Mailing address:
  • Phone: 704-384-9113
  • Fax: 704-316-0508

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number9601462
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: