Provider Demographics
NPI:1710038203
Name:RYAN, LESLEY
Entity Type:Individual
Prefix:
First Name:LESLEY
Middle Name:
Last Name:RYAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19500 SE STARK ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97233-5757
Mailing Address - Country:US
Mailing Address - Phone:503-669-3900
Mailing Address - Fax:
Practice Address - Street 1:19500 SE STARK ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97233-5757
Practice Address - Country:US
Practice Address - Phone:503-669-3900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-13
Last Update Date:2012-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA72919207Q00000X
ORMD151645207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAI06736Medicare UPIN
CA00A729190Medicare ID - Type Unspecified