Provider Demographics
NPI:1003824616
Name:RYAN, SHAIDA KHAJENASIR (MD)
Entity Type:Individual
Prefix:DR
First Name:SHAIDA
Middle Name:KHAJENASIR
Last Name:RYAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 52666
Mailing Address - Street 2:
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27717-2666
Mailing Address - Country:US
Mailing Address - Phone:919-452-5826
Mailing Address - Fax:
Practice Address - Street 1:1515 W NC HIGHWAY 54 STE 210
Practice Address - Street 2:
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27707-5576
Practice Address - Country:US
Practice Address - Phone:919-452-5826
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC162466Medicare UPIN