Provider Demographics
NPI:1407994486
Name:IWAMOTO, RYAN R (ARNP)
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:R
Last Name:IWAMOTO
Suffix:
Gender:M
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1100 OLIVE WAY MSC M4-PA
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98101-1873
Mailing Address - Country:US
Mailing Address - Phone:206-515-5811
Mailing Address - Fax:
Practice Address - Street 1:1100 9TH AVE
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98101-2756
Practice Address - Country:US
Practice Address - Phone:206-223-6801
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-02
Last Update Date:2010-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP30001338363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAUS0863919OtherAETNA SPECIALIST PIN
WA0039573OtherLABOR AND INDUSTRIES#
WA8890564OtherMERICARE PTAN - SNO CO
WA9662222Medicaid
WA8890564OtherMERICARE PTAN - SNO CO
WAUS0863919OtherAETNA SPECIALIST PIN
WA8884111Medicare PIN