Provider Demographics
NPI:1760081962
Name:RYAN, THOMAS P (NP)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:P
Last Name:RYAN
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2003 KOOTENAI HEALTH WAY
Mailing Address - Street 2:
Mailing Address - City:COEUR D ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83814-6051
Mailing Address - Country:US
Mailing Address - Phone:208-625-3555
Mailing Address - Fax:208-765-1494
Practice Address - Street 1:700 W IRONWOOD DR STE 378
Practice Address - Street 2:
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83814-4401
Practice Address - Country:US
Practice Address - Phone:208-625-3555
Practice Address - Fax:208-625-1494
Is Sole Proprietor?:No
Enumeration Date:2020-10-20
Last Update Date:2024-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX96119363LA2100X
IDNP69133363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN7161988OtherDOB