Provider Demographics
NPI:1619024544
Name:BLACK, RYAN DUANE (DO)
Entity Type:Individual
Prefix:DR
First Name:RYAN
Middle Name:DUANE
Last Name:BLACK
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:501 S BURMA AVE
Mailing Address - Street 2:
Mailing Address - City:GILLETTE
Mailing Address - State:WY
Mailing Address - Zip Code:82716-3426
Mailing Address - Country:US
Mailing Address - Phone:307-688-1000
Mailing Address - Fax:
Practice Address - Street 1:501 S BURMA AVE
Practice Address - Street 2:
Practice Address - City:GILLETTE
Practice Address - State:WY
Practice Address - Zip Code:82716-3426
Practice Address - Country:US
Practice Address - Phone:307-688-0110
Practice Address - Fax:307-688-0111
Is Sole Proprietor?:No
Enumeration Date:2007-01-04
Last Update Date:2024-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY14427A207YX0602X, 207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
No207YX0602XAllopathic & Osteopathic PhysiciansOtolaryngologyOtolaryngic Allergy
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK208D00000XOtherTAXONOMY CODE
OK200081850AMedicaid
OK4276OtherSTATE LICENCE
OKBB9432460OtherDEA