Provider Demographics
NPI:1356124432
Name:DALY, RYAN JOSEPH (DNP)
Entity type:Individual
Prefix:
First Name:RYAN
Middle Name:JOSEPH
Last Name:DALY
Suffix:
Gender:M
Credentials:DNP
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 341
Mailing Address - Street 2:
Mailing Address - City:LEWISTON
Mailing Address - State:ID
Mailing Address - Zip Code:83501-0341
Mailing Address - Country:US
Mailing Address - Phone:208-816-3186
Mailing Address - Fax:
Practice Address - Street 1:2841 JUNIPER DR
Practice Address - Street 2:
Practice Address - City:LEWISTON
Practice Address - State:ID
Practice Address - Zip Code:83501-4719
Practice Address - Country:US
Practice Address - Phone:208-848-9001
Practice Address - Fax:208-848-9002
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-14
Last Update Date:2023-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP61475320363L00000X
ID77350363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner