Healthcare Provider Details

I. General information

NPI: 1417671462
Provider Name (Legal Business Name): RYAN MONA RN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/03/2022
Last Update Date: 02/04/2023
Certification Date: 02/04/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

920 STANTON L YOUNG BLVD # WP1140
OKLAHOMA CITY OK
73104-5036
US

IV. Provider business mailing address

PO BOX 26901
OKLAHOMA CITY OK
73126-0901
US

V. Phone/Fax

Practice location:
  • Phone: 405-271-4351
  • Fax:
Mailing address:
  • Phone: 405-271-4351
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WC0200X
TaxonomyCritical Care Medicine Registered Nurse
License NumberRN9412334
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number211142
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: