Provider Demographics
NPI:1033705066
Name:MOONEYHAM, RYAN PATRICK
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:PATRICK
Last Name:MOONEYHAM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:51300 POMERANTZ FAMILY PAVILION
Mailing Address - Street 2:
Mailing Address - City:IOWA CITY
Mailing Address - State:IA
Mailing Address - Zip Code:52242-1049
Mailing Address - Country:US
Mailing Address - Phone:319-356-2205
Mailing Address - Fax:319-335-8956
Practice Address - Street 1:200 HAWKINS DR
Practice Address - Street 2:
Practice Address - City:IOWA CITY
Practice Address - State:IA
Practice Address - Zip Code:52242-1009
Practice Address - Country:US
Practice Address - Phone:319-356-2205
Practice Address - Fax:319-335-8956
Is Sole Proprietor?:No
Enumeration Date:2020-12-14
Last Update Date:2022-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE1731223G0001X
IADDS-09792390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No1223G0001XDental ProvidersDentistGeneral Practice