Provider Demographics
NPI:1568511913
Name:RYAN, MICHELLE ANNE (MD)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:ANNE
Last Name:RYAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10861 CHERRY ST
Mailing Address - Street 2:SUITE 301
Mailing Address - City:LOS ALAMITOS
Mailing Address - State:CA
Mailing Address - Zip Code:90720-5402
Mailing Address - Country:US
Mailing Address - Phone:562-431-3535
Mailing Address - Fax:562-431-6707
Practice Address - Street 1:10861 CHERRY STREET
Practice Address - Street 2:SUITE 301
Practice Address - City:LOS ALAMITOS
Practice Address - State:CA
Practice Address - Zip Code:90720-5407
Practice Address - Country:US
Practice Address - Phone:562-431-3535
Practice Address - Fax:562-431-6707
Is Sole Proprietor?:No
Enumeration Date:2007-01-08
Last Update Date:2012-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA6057030207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA6R0090910Medicaid
F02106Medicare UPIN
W15250Medicare ID - Type Unspecified