Healthcare Provider Details

I. General information

NPI: 1962779579
Provider Name (Legal Business Name): MR. MATTHEW RYAN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/27/2011
Last Update Date: 11/27/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6832 OLD DOMINION DR SUITE 200
MC LEAN VA
22101-3887
US

IV. Provider business mailing address

6832 OLD DOMINION DR SUITE 200
MC LEAN VA
22101-3887
US

V. Phone/Fax

Practice location:
  • Phone: 703-255-1091
  • Fax: 703-255-1091
Mailing address:
  • Phone: 703-255-1091
  • Fax: 703-255-1091

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number0701005058
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: