Healthcare Provider Details

I. General information

NPI: 1770721029
Provider Name (Legal Business Name): RYAN MITCHELL GOLDMAN RPA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/24/2009
Last Update Date: 01/24/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1500 E DOWNING ST
TAHLEQUAH OK
74464-3234
US

IV. Provider business mailing address

4500 S GARNETT RD SUITE919
TULSA OK
74146-5229
US

V. Phone/Fax

Practice location:
  • Phone: 918-453-2146
  • Fax: 918-453-2141
Mailing address:
  • Phone: 918-728-6145
  • Fax: 918-728-6146

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code243U00000X
TaxonomyRadiology Practitioner Assistant
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: