Healthcare Provider Details

I. General information

NPI: 1073851770
Provider Name (Legal Business Name): RYAN MICHAEL ANYANWU
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/30/2013
Last Update Date: 09/12/2024
Certification Date: 09/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3501 W HOLCOMBE BLVD
HOUSTON TX
77025-1313
US

IV. Provider business mailing address

5717 ALBEMARLE RD
CHARLOTTE NC
28212-1634
US

V. Phone/Fax

Practice location:
  • Phone: 281-407-9341
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number2453
License Number StateSC
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0010-06077
License Number StateNC
# 3
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA09054
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: