Provider Demographics
NPI:1629065610
Name:AVERETT, RYAN KENNETH (DPM)
Entity Type:Individual
Prefix:MR
First Name:RYAN
Middle Name:KENNETH
Last Name:AVERETT
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2221 N IRONWOOD CENTER DR
Mailing Address - Street 2:
Mailing Address - City:COEUR D ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83814-2697
Mailing Address - Country:US
Mailing Address - Phone:208-667-3585
Mailing Address - Fax:855-864-8364
Practice Address - Street 1:2221 N IRONWOOD CENTER DR
Practice Address - Street 2:
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83814-2697
Practice Address - Country:US
Practice Address - Phone:208-667-3585
Practice Address - Fax:855-864-8364
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-04
Last Update Date:2016-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDP177213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID806936200Medicaid
P2451OtherBLUE CROSS OF IDAHO
ID000010147409OtherREGENCE BLUE SHIELD
ID1351085OtherMEDICARE
ID806936200Medicaid
P2451OtherBLUE CROSS OF IDAHO