Provider Demographics
NPI:1295194629
Name:GRANGE, RYAN (PA)
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:
Last Name:GRANGE
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12127B HWY 14 N
Mailing Address - Street 2:STE 5
Mailing Address - City:CEDAR CREST
Mailing Address - State:NM
Mailing Address - Zip Code:87008-9499
Mailing Address - Country:US
Mailing Address - Phone:505-281-5180
Mailing Address - Fax:505-281-5320
Practice Address - Street 1:1851 OLD HIGHWAY 66 UNIT 1
Practice Address - Street 2:
Practice Address - City:EDGEWOOD
Practice Address - State:NM
Practice Address - Zip Code:87015
Practice Address - Country:US
Practice Address - Phone:505-286-2396
Practice Address - Fax:505-286-2398
Is Sole Proprietor?:No
Enumeration Date:2016-02-12
Last Update Date:2016-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMPA 2016-0016363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical