Provider Demographics
NPI:1245003466
Name:SAND, RYAN MICHAEL
Entity type:Individual
Prefix:
First Name:RYAN
Middle Name:MICHAEL
Last Name:SAND
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 1:517 KETCH CREEK DR
Mailing Address - Street 2:
Mailing Address - City:LAWTON
Mailing Address - State:OK
Mailing Address - Zip Code:73507-3509
Mailing Address - Country:US
Mailing Address - Phone:940-224-5779
Mailing Address - Fax:
Practice Address - Street 1:5602 SW LEE BLVD
Practice Address - Street 2:
Practice Address - City:LAWTON
Practice Address - State:OK
Practice Address - Zip Code:73505-9699
Practice Address - Country:US
Practice Address - Phone:580-531-4700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-10-31
Last Update Date:2024-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
M0984509146L00000X
OK200875163WF0300X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No146L00000XEmergency Medical Service ProvidersEmergency Medical Technician, Paramedic
No163WF0300XNursing Service ProvidersRegistered NurseFlight