Provider Demographics
NPI:1932115938
Name:RUNYON, RYAN T (DO)
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:T
Last Name:RUNYON
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:PO BOX 1589
Mailing Address - Street 2:
Mailing Address - City:PRINCETON
Mailing Address - State:WV
Mailing Address - Zip Code:24740-1589
Mailing Address - Country:US
Mailing Address - Phone:304-431-7100
Mailing Address - Fax:304-431-7112
Practice Address - Street 1:904 HARRISON ST
Practice Address - Street 2:
Practice Address - City:PRINCETON
Practice Address - State:WV
Practice Address - Zip Code:24740-3011
Practice Address - Country:US
Practice Address - Phone:304-431-7100
Practice Address - Fax:304-431-7112
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-31
Last Update Date:2009-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV2005207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810002620Medicaid
WV3810002620Medicaid