Healthcare Provider Details

I. General information

NPI: 1497737548
Provider Name (Legal Business Name): RYAN ALEC WITHROW D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/15/2005
Last Update Date: 01/07/2025
Certification Date: 01/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2817 ROCK MERRITT AVE WOMACK ARMY MEDICAL CENTER
FORT LIBERTY NC
28310-5901
US

IV. Provider business mailing address

BASTOGNE EXT BLDG 5-4257
FORT BRAGG NC
28310-0001
US

V. Phone/Fax

Practice location:
  • Phone: 910-907-8922
  • Fax: 910-907-6069
Mailing address:
  • Phone: 910-907-9557
  • Fax: 910-570-3360

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number0102201682
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: