Provider Demographics
NPI:1710140249
Name:HACKETT, RYAN ANDREW (MD)
Entity Type:Individual
Prefix:DR
First Name:RYAN
Middle Name:ANDREW
Last Name:HACKETT
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:1505 W ELK AVE
Mailing Address - Street 2:SUITE 2
Mailing Address - City:ELIZABETHTON
Mailing Address - State:TN
Mailing Address - Zip Code:37643-2848
Mailing Address - Country:US
Mailing Address - Phone:423-543-1261
Mailing Address - Fax:423-543-7500
Practice Address - Street 1:1505 W ELK AVE
Practice Address - Street 2:SUITE 2
Practice Address - City:ELIZABETHTON
Practice Address - State:TN
Practice Address - Zip Code:37643-2848
Practice Address - Country:US
Practice Address - Phone:423-543-1261
Practice Address - Fax:423-543-7500
Is Sole Proprietor?:No
Enumeration Date:2008-07-03
Last Update Date:2017-02-02
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
TN52415207Q00000X
NE25511207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ012882Medicaid
TNQ012882Medicaid