Provider Demographics
NPI:1093744468
Name:RYAN, JACQUELYN ANN (MD)
Entity Type:Individual
Prefix:DR
First Name:JACQUELYN
Middle Name:ANN
Last Name:RYAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4815 N ASSEMBLY ST
Mailing Address - Street 2:
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99205-6185
Mailing Address - Country:US
Mailing Address - Phone:509-434-7600
Mailing Address - Fax:
Practice Address - Street 1:4815 N ASSEMBLY ST
Practice Address - Street 2:
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99205-6185
Practice Address - Country:US
Practice Address - Phone:509-434-7602
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-30
Last Update Date:2007-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD40351207RC0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0001XAllopathic & Osteopathic PhysiciansInternal MedicineClinical Cardiac Electrophysiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR000334Medicaid
WA0151249OtherLABOR & INDUSTRIES
WA8284515Medicaid
MT352261Medicaid
MT352261Medicaid
WA0151249OtherLABOR & INDUSTRIES