Provider Demographics
NPI:1477173920
Name:FLANAGAN, RYAN WILLIAM
Entity Type:Individual
Prefix:MR
First Name:RYAN
Middle Name:WILLIAM
Last Name:FLANAGAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:225 26TH ST NW APT 8408
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30309-1901
Mailing Address - Country:US
Mailing Address - Phone:631-807-5979
Mailing Address - Fax:
Practice Address - Street 1:1730 MOUNT VERNON RD STE B
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30338-4245
Practice Address - Country:US
Practice Address - Phone:770-353-2001
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-24
Last Update Date:2022-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA10554363AM0700X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAG29381BMedicaid