Provider Demographics
NPI:1972291953
Name:KNOERDEL, RYAN (PA-C)
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:
Last Name:KNOERDEL
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1005 E KIOWA AVE
Mailing Address - Street 2:
Mailing Address - City:MCALESTER
Mailing Address - State:OK
Mailing Address - Zip Code:74501-5939
Mailing Address - Country:US
Mailing Address - Phone:724-601-6531
Mailing Address - Fax:
Practice Address - Street 1:1 E CLARK BASS BLVD
Practice Address - Street 2:
Practice Address - City:MCALESTER
Practice Address - State:OK
Practice Address - Zip Code:74501-4209
Practice Address - Country:US
Practice Address - Phone:918-421-6753
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-04-27
Last Update Date:2023-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK5035363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant