Provider Demographics
NPI:1255785358
Name:PICKENS, RYAN C
Entity type:Individual
Prefix:
First Name:RYAN
Middle Name:C
Last Name:PICKENS
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 1:1000 BLYTHE BLVD
Mailing Address - Street 2:SUITE 601
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28203-5812
Mailing Address - Country:US
Mailing Address - Phone:704-355-7874
Mailing Address - Fax:704-355-5619
Practice Address - Street 1:1000 BLYTHE BLVD
Practice Address - Street 2:SUITE 601
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28203-5812
Practice Address - Country:US
Practice Address - Phone:704-355-7874
Practice Address - Fax:704-355-5619
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-15
Last Update Date:2016-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC218749208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC218749OtherNORTH CAROLINA MEDICAL BOARD RESIDENCY TRAINING LICENSE FILE ID#