Provider Demographics
NPI:1831493196
Name:RYAN, JAMES LEE (FNP-C)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:LEE
Last Name:RYAN
Suffix:
Gender:M
Credentials:FNP-C
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 550
Mailing Address - Street 2:
Mailing Address - City:VANCEBURG
Mailing Address - State:KY
Mailing Address - Zip Code:41179-0550
Mailing Address - Country:US
Mailing Address - Phone:606-796-3029
Mailing Address - Fax:606-796-6221
Practice Address - Street 1:142 DEPOT DRIVE
Practice Address - Street 2:
Practice Address - City:SOUTH SHORE
Practice Address - State:KY
Practice Address - Zip Code:41175
Practice Address - Country:US
Practice Address - Phone:606-932-2271
Practice Address - Fax:606-932-2273
Is Sole Proprietor?:No
Enumeration Date:2010-12-30
Last Update Date:2011-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY6463P363LF0000X
KY3006463363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100149730Medicaid
OH3124096Medicaid
P400037218Medicare PIN