Provider Demographics
NPI:1871848846
Name:THORDAL, RYAN J (DO)
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:J
Last Name:THORDAL
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:324 N EMPORIA AVE APT 321
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67202-2548
Mailing Address - Country:US
Mailing Address - Phone:218-415-1462
Mailing Address - Fax:
Practice Address - Street 1:57950 LEAVENWORTH ST
Practice Address - Street 2:
Practice Address - City:MCCONNELL AFB
Practice Address - State:KS
Practice Address - Zip Code:67221-3506
Practice Address - Country:US
Practice Address - Phone:316-759-5116
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-17
Last Update Date:2018-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA253114207R00000X
MN57333208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine