Provider Demographics
NPI:1689069130
Name:ANDERSON, RYAN
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:
Last Name:ANDERSON
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 1:3535 OLENTANGY RIVER RD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43214-3908
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3535 OLENTANGY RIVER RD
Practice Address - Street 2:SUITE 200
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43214-3908
Practice Address - Country:US
Practice Address - Phone:614-566-2426
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-04-01
Last Update Date:2021-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD470803390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program