Healthcare Provider Details

I. General information

NPI: 1184294696
Provider Name (Legal Business Name): RYAN WALTER YOUNG
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/28/2021
Last Update Date: 05/08/2024
Certification Date: 05/08/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

744 W 9TH ST
TULSA OK
74127-9907
US

IV. Provider business mailing address

1430 N VINITA AVE
TAHLEQUAH OK
74464-6434
US

V. Phone/Fax

Practice location:
  • Phone: 918-599-1000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number8056
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: