Provider Demographics
NPI:1235270133
Name:RYAN, SARA LOUISE (DA)
Entity Type:Individual
Prefix:DR
First Name:SARA
Middle Name:LOUISE
Last Name:RYAN
Suffix:
Gender:F
Credentials:DA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:130 GANO STREET
Mailing Address - Street 2:
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02906-0290
Mailing Address - Country:US
Mailing Address - Phone:401-261-6247
Mailing Address - Fax:401-223-0160
Practice Address - Street 1:130 GANO STREET
Practice Address - Street 2:
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02906-0290
Practice Address - Country:US
Practice Address - Phone:401-261-6247
Practice Address - Fax:401-223-0160
Is Sole Proprietor?:No
Enumeration Date:2007-02-12
Last Update Date:2008-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIDA00202171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI32107-7OtherBLUE CROSS BLUE SHIELD RI