Provider Demographics
NPI:1558964445
Name:MOGADAM, RYAN CHRISTOPHER
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:CHRISTOPHER
Last Name:MOGADAM
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 1:19 LOCKHOUSE RD APT 2-4
Mailing Address - Street 2:
Mailing Address - City:WESTFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:01085-1202
Mailing Address - Country:US
Mailing Address - Phone:703-618-3116
Mailing Address - Fax:
Practice Address - Street 1:1176 MEMORIAL DR
Practice Address - Street 2:
Practice Address - City:CHICOPEE
Practice Address - State:MA
Practice Address - Zip Code:01020-3958
Practice Address - Country:US
Practice Address - Phone:703-618-3116
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-21
Last Update Date:2021-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical