=====================================================
General NPI Number Information
=====================================================
NPI Number | 1104888916
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MICHAEL E RYAN MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/05/2006
-----------------------------------------------------
Last Update Date | 12/17/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5901 N LIDGERWOOD ST STE 118
-----------------------------------------------------
City | SPOKANE
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 99208-1122
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 509-483-2828
-----------------------------------------------------
Fax | 509-484-7882
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5901 N LIDGERWOOD ST STE 118
-----------------------------------------------------
City | SPOKANE
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 99208-1122
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 509-483-2828
-----------------------------------------------------
Fax | 509-484-7882
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207N00000X
-----------------------------------------------------
Taxonomy Name | Dermatology Physician
-----------------------------------------------------
License Number | MD00019784
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------