Provider Demographics
NPI:1821087859
Name:MCKINNON, RYAN S (MD-OPTHALMOLOGY)
Entity Type:Individual
Prefix:MR
First Name:RYAN
Middle Name:S
Last Name:MCKINNON
Suffix:
Gender:M
Credentials:MD-OPTHALMOLOGY
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:215 E HAWAII AVE
Mailing Address - Street 2:
Mailing Address - City:NAMPA
Mailing Address - State:ID
Mailing Address - Zip Code:83686-6011
Mailing Address - Country:US
Mailing Address - Phone:208-463-3000
Mailing Address - Fax:
Practice Address - Street 1:215 E HAWAII AVE
Practice Address - Street 2:
Practice Address - City:NAMPA
Practice Address - State:ID
Practice Address - Zip Code:83686-6011
Practice Address - Country:US
Practice Address - Phone:208-455-2355
Practice Address - Fax:208-465-4825
Is Sole Proprietor?:No
Enumeration Date:2005-10-21
Last Update Date:2021-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM6206207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDDM255OtherBLUE CROSS
ID1821087859Medicaid
ID12062OtherBLUE CROSS
ID080036991OtherRAILROAD MEDICARE
ID20002185Medicare PIN
ID12062OtherBLUE CROSS
F59864Medicare UPIN