Healthcare Provider Details

I. General information

NPI: 1295194629
Provider Name (Legal Business Name): RYAN GRANGE P.A
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/12/2016
Last Update Date: 04/14/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1851 OLD HIGHWAY 66 UNIT 1
EDGEWOOD NM
87015
US

IV. Provider business mailing address

12127B HWY 14 N STE 5
CEDAR CREST NM
87008-9499
US

V. Phone/Fax

Practice location:
  • Phone: 505-286-2396
  • Fax: 505-286-2398
Mailing address:
  • Phone: 505-281-5180
  • Fax: 505-281-5320

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA 2016-0016
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: