Provider Demographics
NPI:1508506155
Name:DOUGHERTY, RYAN
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:
Last Name:DOUGHERTY
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:PO BOX 119
Mailing Address - Street 2:
Mailing Address - City:STATE UNIVERSITY
Mailing Address - State:AR
Mailing Address - Zip Code:72467-0119
Mailing Address - Country:US
Mailing Address - Phone:870-972-2786
Mailing Address - Fax:
Practice Address - Street 1:2405 AGGIE ROAD
Practice Address - Street 2:WILSON HALL
Practice Address - City:JONESBORO
Practice Address - State:AR
Practice Address - Zip Code:72401
Practice Address - Country:US
Practice Address - Phone:870-972-2786
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-31
Last Update Date:2022-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QS1000XAmbulatory Health Care FacilitiesClinic/CenterStudent Health