MEDICARE: KELLY RYAN MACHUCA MD

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	207QS0010X	Sports Medicine (Family Medicine) Physician	MD489557	PA

General Provider Information

NPI Number	:	1255915930
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KELLY RYAN MACHUCA MD

Provider Business Mailing Address
First Line	:	1201 GRAMPIAN BLVD
Second Line	:
City	:	WILLIAMSPORT
State	:	PA
Zip	:	17701-1900
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	700 HIGH ST
Second Line	:
City	:	WILLIAMSPORT
State	:	PA
Zip	:	17701-3100
Country	:	US
Telephone Number	:	570-321-2620
Fax Number	:

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

Provider Enumeration Date	:	05/10/2021
Last Update Date	:	04/29/2026

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