Provider Demographics
NPI:1548200504
Name:RYAN, JEFF L (MD)
Entity Type:Individual
Prefix:
First Name:JEFF
Middle Name:L
Last Name:RYAN
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:PO BOX 7132
Mailing Address - Street 2:
Mailing Address - City:KETCHIKAN
Mailing Address - State:AK
Mailing Address - Zip Code:99901-2132
Mailing Address - Country:US
Mailing Address - Phone:907-228-0185
Mailing Address - Fax:
Practice Address - Street 1:7559 N TONGASS HWY
Practice Address - Street 2:
Practice Address - City:KETCHIKAN
Practice Address - State:AK
Practice Address - Zip Code:99901-9182
Practice Address - Country:US
Practice Address - Phone:907-228-0185
Practice Address - Fax:907-225-0184
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-07
Last Update Date:2023-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK116345208600000X
ALMD22074208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL123075Medicaid
G94262Medicare UPIN
AL123075Medicaid