Healthcare Provider Details

I. General information

NPI: 1073837704
Provider Name (Legal Business Name): RYAN HODNICK DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/24/2010
Last Update Date: 12/28/2020
Certification Date: 12/22/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

80 B VETERANS BLVD
PUEBLO OF ACOMA NM
87034
US

IV. Provider business mailing address

P.O. BOX 130
SAN FIDEL NM
87049-0130
US

V. Phone/Fax

Practice location:
  • Phone: 505-552-5300
  • Fax: 505-552-5490
Mailing address:
  • Phone: 505-552-5300
  • Fax: 505-552-5490

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberA-1756-13
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: