Provider Demographics
NPI:1083297220
Name:MCBRIDE, RYAN
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:
Last Name:MCBRIDE
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 1:123 S 19TH AVE
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83201-3339
Mailing Address - Country:US
Mailing Address - Phone:208-339-1579
Mailing Address - Fax:
Practice Address - Street 1:210 S EMERSON AVE
Practice Address - Street 2:
Practice Address - City:SHELLEY
Practice Address - State:ID
Practice Address - Zip Code:83274-1229
Practice Address - Country:US
Practice Address - Phone:208-375-7404
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-05
Last Update Date:2021-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDF05210086363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily