Provider Demographics
NPI:1922325539
Name:SWAN, RYAN
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:
Last Name:SWAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1351 ROUTE 55 STE 200
Mailing Address - Street 2:
Mailing Address - City:LAGRANGEVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:12540-5128
Mailing Address - Country:US
Mailing Address - Phone:845-475-9661
Mailing Address - Fax:845-475-9938
Practice Address - Street 1:45 READE PL FL 3
Practice Address - Street 2:
Practice Address - City:POUGHKEEPSIE
Practice Address - State:NY
Practice Address - Zip Code:12601
Practice Address - Country:US
Practice Address - Phone:845-483-6920
Practice Address - Fax:845-483-6922
Is Sole Proprietor?:No
Enumeration Date:2010-04-23
Last Update Date:2018-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY9794583208600000X, 208600000X
NY2824122086X0206X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Yes2086X0206XAllopathic & Osteopathic PhysiciansSurgerySurgical Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY04358343Medicaid
NC1922325539Medicaid
SCNC1142Medicaid
NC5915328Medicaid