Healthcare Provider Details

I. General information

NPI: 1720240286
Provider Name (Legal Business Name): RYAN LOUIS ROBERTS M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/26/2008
Last Update Date: 09/26/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9040A FITZSIMMONS AVE
JBLM-TACOMA WA
98431-1100
US

IV. Provider business mailing address

9040A FITZSIMMONS AVE
JBLM-TACOMA WA
98431-1100
US

V. Phone/Fax

Practice location:
  • Phone: 253-968-1760
  • Fax:
Mailing address:
  • Phone: 253-968-1760
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number0101247018
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: