Provider Demographics
NPI:1528222460
Name:HARRISON, RYAN (MD)
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:
Last Name:HARRISON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2106 LOOP RD
Mailing Address - Street 2:
Mailing Address - City:WINNSBORO
Mailing Address - State:LA
Mailing Address - Zip Code:71295-3344
Mailing Address - Country:US
Mailing Address - Phone:318-435-9411
Mailing Address - Fax:318-435-9411
Practice Address - Street 1:2106 LOOP RD
Practice Address - Street 2:
Practice Address - City:WINNSBORO
Practice Address - State:LA
Practice Address - Zip Code:71295-3344
Practice Address - Country:US
Practice Address - Phone:318-435-9411
Practice Address - Fax:318-435-6519
Is Sole Proprietor?:No
Enumeration Date:2008-07-10
Last Update Date:2021-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAMD.206301207P00000X
MO2011026644207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2342614Medicaid
MOH75000008OtherMEDICARE UNSPECIFIED