Healthcare Provider Details

I. General information

NPI: 1871007187
Provider Name (Legal Business Name): RYAN A MCCUNE PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/22/2017
Last Update Date: 08/19/2022
Certification Date: 08/18/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 MATTHEW ST STE 302
MARIETTA OH
45750-1656
US

IV. Provider business mailing address

416 COLEGATE DR BLDG 3
MARIETTA OH
45750-9549
US

V. Phone/Fax

Practice location:
  • Phone: 740-568-5207
  • Fax: 740-568-5297
Mailing address:
  • Phone: 740-568-4814
  • Fax: 740-374-3165

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number2115
License Number StateWV
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number50.007378RX
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: