Provider Demographics
NPI:1659356905
Name:RYAN, KATHLEEN L (MD)
Entity type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:L
Last Name:RYAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3412 PENNINGTON DR
Mailing Address - Street 2:
Mailing Address - City:WALPOLE
Mailing Address - State:MA
Mailing Address - Zip Code:02081-1078
Mailing Address - Country:US
Mailing Address - Phone:609-744-8046
Mailing Address - Fax:815-331-0775
Practice Address - Street 1:3412 PENNINGTON DR
Practice Address - Street 2:
Practice Address - City:WALPOLE
Practice Address - State:MA
Practice Address - Zip Code:02081-1078
Practice Address - Country:US
Practice Address - Phone:609-744-8046
Practice Address - Fax:815-331-0775
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-09
Last Update Date:2024-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA04982500174400000X, 207RP1001X, 207RS0012X
MA50223174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
No207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No207RS0012XAllopathic & Osteopathic PhysiciansInternal MedicineSleep Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA50223OtherMA LICENSE
NJ0123803Medicaid
NJE13252Medicare UPIN