Provider Demographics
NPI:1164996948
Name:BLACKWELL, RYAN J
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:J
Last Name:BLACKWELL
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 1:30 13TH ST
Mailing Address - Street 2:
Mailing Address - City:HAVRE
Mailing Address - State:MT
Mailing Address - Zip Code:59501-5222
Mailing Address - Country:US
Mailing Address - Phone:406-262-1305
Mailing Address - Fax:406-265-1651
Practice Address - Street 1:30 13TH ST
Practice Address - Street 2:
Practice Address - City:HAVRE
Practice Address - State:MT
Practice Address - Zip Code:59501
Practice Address - Country:US
Practice Address - Phone:406-262-1305
Practice Address - Fax:406-265-1651
Is Sole Proprietor?:No
Enumeration Date:2019-01-15
Last Update Date:2023-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant