Provider Demographics
NPI:1902229065
Name:RYAN, MICHAEL THOMAS (CM1, PRSS)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:THOMAS
Last Name:RYAN
Suffix:
Gender:M
Credentials:CM1, PRSS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5208 CLASSEN CIR
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73118-4429
Mailing Address - Country:US
Mailing Address - Phone:405-810-1766
Mailing Address - Fax:405-810-0331
Practice Address - Street 1:5208 CLASSEN CIR
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73118-4429
Practice Address - Country:US
Practice Address - Phone:405-810-1766
Practice Address - Fax:405-810-0331
Is Sole Proprietor?:Yes
Enumeration Date:2014-01-27
Last Update Date:2014-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK251B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management