Provider Demographics
NPI:1104372739
Name:COUGHLIN, RYAN PHILLIP
Entity Type:Individual
Prefix:DR
First Name:RYAN
Middle Name:PHILLIP
Last Name:COUGHLIN
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 1:2616 ERWIN RD
Mailing Address - Street 2:2548
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27705-3843
Mailing Address - Country:US
Mailing Address - Phone:984-220-1035
Mailing Address - Fax:
Practice Address - Street 1:2616 ERWIN RD.
Practice Address - Street 2:2548
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27705-3843
Practice Address - Country:US
Practice Address - Phone:984-220-1035
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-01
Last Update Date:2016-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2016-01497390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program