Provider Demographics
NPI:1407847833
Name:ANDERSON, RYAN W (PA-C)
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:W
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:401 6TH AVE
Mailing Address - Street 2:
Mailing Address - City:MONTGOMERY
Mailing Address - State:WV
Mailing Address - Zip Code:25136-2116
Mailing Address - Country:US
Mailing Address - Phone:304-442-5151
Mailing Address - Fax:
Practice Address - Street 1:3701 MACCORKLE AVE SE
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25304-1525
Practice Address - Country:US
Practice Address - Phone:304-442-5151
Practice Address - Fax:304-442-7494
Is Sole Proprietor?:No
Enumeration Date:2005-11-03
Last Update Date:2021-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV01148363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV374OtherWV BD. OSTEO LICENSE
WV01148OtherSTATE LICENSE NUMBER
WVPA25667Medicare PIN
WVQ53678Medicare UPIN