Provider Demographics
NPI:1184823064
Name:MCNABB, RYAN G (PA)
Entity type:Individual
Prefix:MR
First Name:RYAN
Middle Name:G
Last Name:MCNABB
Suffix:
Gender:M
Credentials:PA
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 634760
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45263-0001
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1114 W MADISON AVE
Practice Address - Street 2:
Practice Address - City:ATHENS
Practice Address - State:TN
Practice Address - Zip Code:37303-4150
Practice Address - Country:US
Practice Address - Phone:423-745-1411
Practice Address - Fax:865-539-8008
Is Sole Proprietor?:No
Enumeration Date:2007-07-12
Last Update Date:2007-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNPA1514363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN4159770OtherBLUE CROSS
TN3665087Medicare PIN