Healthcare Provider Details

I. General information

NPI: 1376004085
Provider Name (Legal Business Name): RYAN DANIEL FARIAS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/26/2019
Last Update Date: 05/10/2026
Certification Date: 05/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1215 LEE STREET BOX #800793
CHARLOTTESVILLE VA
22908-0816
US

IV. Provider business mailing address

19 BRADHURST AVE STE 3100N
HAWTHORNE NY
10532-2140
US

V. Phone/Fax

Practice location:
  • Phone: 434-924-1955
  • Fax: 434-245-2010
Mailing address:
  • Phone: 914-231-8373
  • Fax: 914-909-9028

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number342004
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number0116037534
License Number StateVA
# 3
Primary TaxonomyN
Taxonomy Code207VM0101X
TaxonomyMaternal & Fetal Medicine Physician
License Number342004
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: