Healthcare Provider Details

I. General information

NPI: 1003092701
Provider Name (Legal Business Name): RYAN P. TYNER M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/14/2008
Last Update Date: 03/16/2020
Certification Date: 03/16/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10511 GOLF COURSE RD NW
ALBUQUERQUE NM
87114-5916
US

IV. Provider business mailing address

PO BOX 26028
ALBUQUERQUE NM
87125-6028
US

V. Phone/Fax

Practice location:
  • Phone: 505-262-7281
  • Fax:
Mailing address:
  • Phone: 505-232-1617
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberN6734
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberMD2012-0220
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: