Provider Demographics
NPI:1972669455
Name:PATTERSON, RYAN TREVOR (DCNP)
Entity Type:Individual
Prefix:MR
First Name:RYAN
Middle Name:TREVOR
Last Name:PATTERSON
Suffix:
Gender:M
Credentials:DCNP
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 3445
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46206-3445
Mailing Address - Country:US
Mailing Address - Phone:812-994-1404
Mailing Address - Fax:
Practice Address - Street 1:1600 E SPRINGHILL DR
Practice Address - Street 2:
Practice Address - City:TERRE HAUTE
Practice Address - State:IN
Practice Address - Zip Code:47802-4363
Practice Address - Country:US
Practice Address - Phone:812-994-1404
Practice Address - Fax:812-742-9420
Is Sole Proprietor?:No
Enumeration Date:2006-12-29
Last Update Date:2020-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAP4948363L00000X
AZAZ4948207N00000X
IN71001628A363L00000X, 207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
INZ169490Medicare PIN