Provider Demographics
NPI:1033746284
Name:NUNNERY, RYAN
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:
Last Name:NUNNERY
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 1:154 KNABNER RD
Mailing Address - Street 2:
Mailing Address - City:MECHANICVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:12118-9707
Mailing Address - Country:US
Mailing Address - Phone:518-879-7911
Mailing Address - Fax:
Practice Address - Street 1:154 KNABNER RD
Practice Address - Street 2:
Practice Address - City:MECHANICVILLE
Practice Address - State:NY
Practice Address - Zip Code:12118-9707
Practice Address - Country:US
Practice Address - Phone:518-879-7911
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-26
Last Update Date:2020-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY158404469344600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes344600000XTransportation ServicesTaxi
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY158404469Medicaid