Provider Demographics
NPI:1891147757
Name:EAST, RYAN (HAS)
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:
Last Name:EAST
Suffix:
Gender:M
Credentials:HAS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:516 OWEN DR
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28304-3432
Mailing Address - Country:US
Mailing Address - Phone:910-486-4327
Mailing Address - Fax:
Practice Address - Street 1:516 OWEN DR
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28304-3432
Practice Address - Country:US
Practice Address - Phone:910-486-4327
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-05
Last Update Date:2016-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1501172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker