Provider Demographics
NPI:1376631812
Name:GOUGH, RYAN CONOR (MD)
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:CONOR
Last Name:GOUGH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PSC 41 BOX 6082
Mailing Address - Street 2:
Mailing Address - City:APO
Mailing Address - State:AE
Mailing Address - Zip Code:09464-0061
Mailing Address - Country:US
Mailing Address - Phone:314-238-2143
Mailing Address - Fax:
Practice Address - Street 1:RAF LAKENHEATH 48 MDG/SGHC
Practice Address - Street 2:UNIT 5115
Practice Address - City:APO
Practice Address - State:AE
Practice Address - Zip Code:09464-5115
Practice Address - Country:US
Practice Address - Phone:314-226-8852
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-10
Last Update Date:2018-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE5495207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE1376631812Medicaid