MEDICARE: MR. RYAN HEROLD FNP-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LF0000X	Family Nurse Practitioner	220211	AZ

General Provider Information

NPI Number	:	1174095590
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. RYAN HEROLD FNP-C

Provider Business Mailing Address
First Line	:	4326 E SANDIA ST
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85044-3946
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2901 N CENTRAL AVE
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85012-2700
Country	:	US
Telephone Number	:	602-747-4000
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/24/2018
Last Update Date	:	03/22/2021

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