Healthcare Provider Details

I. General information

NPI: 1902229065
Provider Name (Legal Business Name): MICHAEL THOMAS RYAN CM1, PRSS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/27/2014
Last Update Date: 01/27/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5208 CLASSEN CIR
OKLAHOMA CITY OK
73118-4429
US

IV. Provider business mailing address

5208 CLASSEN CIR
OKLAHOMA CITY OK
73118-4429
US

V. Phone/Fax

Practice location:
  • Phone: 405-810-1766
  • Fax: 405-810-0331
Mailing address:
  • Phone: 405-810-1766
  • Fax: 405-810-0331

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: