Provider Demographics
NPI:1619745395
Name:SKIDMORE, RYAN
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:
Last Name:SKIDMORE
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 1:2065 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:LUMBERPORT
Mailing Address - State:WV
Mailing Address - Zip Code:26386-8070
Mailing Address - Country:US
Mailing Address - Phone:681-253-1613
Mailing Address - Fax:
Practice Address - Street 1:2065 MAIN ST
Practice Address - Street 2:
Practice Address - City:LUMBERPORT
Practice Address - State:WV
Practice Address - Zip Code:26386-8070
Practice Address - Country:US
Practice Address - Phone:681-253-1613
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-12-13
Last Update Date:2023-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker