Provider Demographics
NPI:1184931446
Name:DAUGHERTY, RYAN WRIGHT
Entity type:Individual
Prefix:MR
First Name:RYAN
Middle Name:WRIGHT
Last Name:DAUGHERTY
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 1:300 PASTEUR DR
Mailing Address - Street 2:H3652 MC 5642
Mailing Address - City:STANFORD
Mailing Address - State:CA
Mailing Address - Zip Code:94305-2200
Mailing Address - Country:US
Mailing Address - Phone:650-736-9081
Mailing Address - Fax:650-736-7734
Practice Address - Street 1:300 PASTEUR DR
Practice Address - Street 2:H3652 MC 5642
Practice Address - City:STANFORD
Practice Address - State:CA
Practice Address - Zip Code:94305-2200
Practice Address - Country:US
Practice Address - Phone:650-736-9081
Practice Address - Fax:650-736-7734
Is Sole Proprietor?:No
Enumeration Date:2010-09-08
Last Update Date:2016-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA16794363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care