Healthcare Provider Details

I. General information

NPI: 1275095457
Provider Name (Legal Business Name): RYAN SHIBATA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/05/2019
Last Update Date: 12/19/2025
Certification Date: 12/19/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 E 3RD ST
CHATTANOOGA TN
37403-2241
US

IV. Provider business mailing address

214 GRAY CREEK RD
GRAYSVILLE TN
37338-4734
US

V. Phone/Fax

Practice location:
  • Phone: 423-778-2957
  • Fax:
Mailing address:
  • Phone: 760-636-6741
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number67565
License Number StateTN
# 2
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License NumberE-20029
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: