Healthcare Provider Details

I. General information

NPI: 1407847833
Provider Name (Legal Business Name): RYAN W ANDERSON PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/03/2005
Last Update Date: 12/13/2021
Certification Date: 12/13/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3701 MACCORKLE AVE SE
CHARLESTON WV
25304-1525
US

IV. Provider business mailing address

401 6TH AVE
MONTGOMERY WV
25136-2116
US

V. Phone/Fax

Practice location:
  • Phone: 304-442-5151
  • Fax: 304-442-7494
Mailing address:
  • Phone: 304-442-5151
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number01148
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: