Healthcare Provider Details

I. General information

NPI: 1083100408
Provider Name (Legal Business Name): RYAN MICHAEL MCVAIGH PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/09/2018
Last Update Date: 11/08/2021
Certification Date: 11/08/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2546 BALLTOWN RD
SCHENECTADY NY
12309-1082
US

IV. Provider business mailing address

PO BOX 14890
ALBANY NY
12212-4890
US

V. Phone/Fax

Practice location:
  • Phone: 518-377-8184
  • Fax:
Mailing address:
  • Phone: 518-525-5634
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number022158-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: