Provider Demographics
NPI:1033639752
Name:ROMER, RYAN CHARLES (IDC)
Entity Type:Individual
Prefix:MR
First Name:RYAN
Middle Name:CHARLES
Last Name:ROMER
Suffix:
Gender:M
Credentials:IDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:929 MANDARIN TRL
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28540-9643
Mailing Address - Country:US
Mailing Address - Phone:916-778-8770
Mailing Address - Fax:
Practice Address - Street 1:814 RADFORD BLVD STE 20328
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:GA
Practice Address - Zip Code:31704-1130
Practice Address - Country:US
Practice Address - Phone:229-639-5980
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-23
Last Update Date:2020-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman