Provider Demographics
NPI:1891877395
Name:AGENA, RYAN HIDEO (MD)
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:HIDEO
Last Name:AGENA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:3110 CHINO AVE STE 150A
Mailing Address - Street 2:
Mailing Address - City:CHINO HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91709-1295
Mailing Address - Country:US
Mailing Address - Phone:909-630-7490
Mailing Address - Fax:909-469-2108
Practice Address - Street 1:3110 CHINO AVE STE 150A
Practice Address - Street 2:
Practice Address - City:CHINO HILLS
Practice Address - State:CA
Practice Address - Zip Code:91709-1295
Practice Address - Country:US
Practice Address - Phone:909-630-7490
Practice Address - Fax:909-469-2107
Is Sole Proprietor?:No
Enumeration Date:2006-10-20
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CA20A9676207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
11744679OtherCAQH
11744679OtherCAQH
BA9983037OtherDEA
BK462YMedicare PIN