Provider Demographics
NPI:1407912157
Name:RYAN, MATTHEW WALTER (DC)
Entity Type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:WALTER
Last Name:RYAN
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 491
Mailing Address - Street 2:
Mailing Address - City:WINDER
Mailing Address - State:GA
Mailing Address - Zip Code:30680-0491
Mailing Address - Country:US
Mailing Address - Phone:770-867-2225
Mailing Address - Fax:770-867-7161
Practice Address - Street 1:206 E MAY ST
Practice Address - Street 2:
Practice Address - City:WINDER
Practice Address - State:GA
Practice Address - Zip Code:30680-7127
Practice Address - Country:US
Practice Address - Phone:770-867-2225
Practice Address - Fax:770-867-7161
Is Sole Proprietor?:No
Enumeration Date:2006-12-28
Last Update Date:2013-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACHIR005174111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA35ZCHTJMedicare PIN
GAU65328Medicare UPIN