Healthcare Provider Details

I. General information

NPI: 1316352651
Provider Name (Legal Business Name): RYAN GARDNER MAXWELL NP-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/25/2014
Last Update Date: 12/12/2025
Certification Date: 12/12/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8905 SW NIMBUS AVE STE 300
BEAVERTON OR
97008-7162
US

IV. Provider business mailing address

8314 SW 9TH AVE
PORTLAND OR
97219-4407
US

V. Phone/Fax

Practice location:
  • Phone: 503-352-0468
  • Fax:
Mailing address:
  • Phone: 469-338-9262
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAP125872
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: