Provider Demographics
NPI:1619067436
Name:VAN DE GRAAFF, RYAN LEWIS (MD)
Entity Type:Individual
Prefix:DR
First Name:RYAN
Middle Name:LEWIS
Last Name:VAN DE GRAAFF
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 1:900 N. LIBERTY ST.
Mailing Address - Street 2:STE 400
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83704
Mailing Address - Country:US
Mailing Address - Phone:208-367-3320
Mailing Address - Fax:208-367-7474
Practice Address - Street 1:900 N LIBERTY ST.
Practice Address - Street 2:STE 400
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83704
Practice Address - Country:US
Practice Address - Phone:208-367-3320
Practice Address - Fax:208-367-7474
Is Sole Proprietor?:No
Enumeration Date:2006-10-13
Last Update Date:2010-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE22476207Y00000X
IDM-10288207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID808096700Medicaid
H83273Medicare UPIN
ID808096700Medicaid