Provider Demographics
NPI:1073851770
Name:ANYANWU, RYAN
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:
Last Name:ANYANWU
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 1:5717 ALBEMARLE RD
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28212-1634
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5717 ALBEMARLE RD
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28212-1634
Practice Address - Country:US
Practice Address - Phone:704-563-2150
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-01-30
Last Update Date:2019-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC2453363A00000X
NC0010-06077363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC2465PAMedicaid
NC1073851770Medicaid
NC1073851770Medicaid
NCNCR004CMedicare PIN
NCNCR004DMedicare PIN
NCNCR004AMedicare PIN
NCNCR004EMedicare PIN