Provider Demographics
NPI:1710330113
Name:RYAN, LUNDEN LISTON (MD)
Entity Type:Individual
Prefix:
First Name:LUNDEN
Middle Name:LISTON
Last Name:RYAN
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:PO BOX 9196
Mailing Address - Street 2:
Mailing Address - City:MORGANTOWN
Mailing Address - State:WV
Mailing Address - Zip Code:26506-9196
Mailing Address - Country:US
Mailing Address - Phone:304-293-1168
Mailing Address - Fax:
Practice Address - Street 1:612 WASHINGTON BLVD
Practice Address - Street 2:
Practice Address - City:BELPRE
Practice Address - State:OH
Practice Address - Zip Code:45714-2465
Practice Address - Country:US
Practice Address - Phone:304-485-8040
Practice Address - Fax:304-485-4883
Is Sole Proprietor?:No
Enumeration Date:2016-07-20
Last Update Date:2022-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35.146094207XX0801X
WV28383207XX0801X
WV390200000X
KYTP213207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
No207XX0801XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryOrthopaedic Trauma
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV1710330113Medicaid