Provider Demographics
NPI:1144746108
Name:RYAN, ANTHONY GERARD (RN)
Entity Type:Individual
Prefix:
First Name:ANTHONY
Middle Name:GERARD
Last Name:RYAN
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:151 KALMUS DR STE 145
Mailing Address - Street 2:
Mailing Address - City:COSTA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:92626-5988
Mailing Address - Country:US
Mailing Address - Phone:714-966-8650
Mailing Address - Fax:
Practice Address - Street 1:590 TRAVERSE DR
Practice Address - Street 2:
Practice Address - City:COSTA MESA
Practice Address - State:CA
Practice Address - Zip Code:92626-3117
Practice Address - Country:US
Practice Address - Phone:714-966-8650
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-21
Last Update Date:2017-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95024953163WP0808X, 163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health