Provider Demographics
NPI:1396824546
Name:RYAN, GORDON A (MD)
Entity Type:Individual
Prefix:DR
First Name:GORDON
Middle Name:A
Last Name:RYAN
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 1:1023 NIPOMO ST STE 110
Mailing Address - Street 2:
Mailing Address - City:SAN LUIS OBISPO
Mailing Address - State:CA
Mailing Address - Zip Code:93401-6155
Mailing Address - Country:US
Mailing Address - Phone:805-439-2998
Mailing Address - Fax:805-439-2997
Practice Address - Street 1:1010 MURRAY AVE
Practice Address - Street 2:
Practice Address - City:SAN LUIS OBISPO
Practice Address - State:CA
Practice Address - Zip Code:93405
Practice Address - Country:US
Practice Address - Phone:805-439-2998
Practice Address - Fax:805-439-2997
Is Sole Proprietor?:No
Enumeration Date:2006-11-06
Last Update Date:2018-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC145619207R00000X, 208M00000X
VA0101034688207R00000X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA005878900Medicaid
VA12085OtherSENTARA HEALTH PLANS
VA00V006G74Medicare PIN
VA005878900Medicaid