Provider Demographics
NPI:1144606229
Name:FAIRLEY, RYAN
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:
Last Name:FAIRLEY
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:PO BOX 3808
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97208-3808
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1040 NW 22ND AVE STE 520
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97210-3097
Practice Address - Country:US
Practice Address - Phone:503-413-7557
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-30
Last Update Date:2020-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORDO197810208600000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORPENDINGMedicaid