Provider Demographics
NPI:1659573889
Name:HEYBORNE, RYAN DANIEL (MD)
Entity Type:Individual
Prefix:DR
First Name:RYAN
Middle Name:DANIEL
Last Name:HEYBORNE
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 1:3340 E GOLDSTONE WAY
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-1026
Mailing Address - Country:US
Mailing Address - Phone:208-302-6400
Mailing Address - Fax:208-302-6455
Practice Address - Street 1:3025 W CHERRY LANE
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642
Practice Address - Country:US
Practice Address - Phone:208-302-6400
Practice Address - Fax:208-302-6455
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-01
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01062424A207P00000X
IDM10210207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID808011700Medicaid
ID1100254Medicare PIN