Provider Demographics
NPI:1740673920
Name:MOELLENKAMP, RYAN CHRIS (PA)
Entity type:Individual
Prefix:
First Name:RYAN
Middle Name:CHRIS
Last Name:MOELLENKAMP
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:90 VERMONT AVE STE 300
Mailing Address - Street 2:
Mailing Address - City:OAK RIDGE
Mailing Address - State:TN
Mailing Address - Zip Code:37830-6478
Mailing Address - Country:US
Mailing Address - Phone:865-481-2541
Mailing Address - Fax:865-483-8151
Practice Address - Street 1:90 VERMONT AVE STE 300
Practice Address - Street 2:
Practice Address - City:OAK RIDGE
Practice Address - State:TN
Practice Address - Zip Code:37830-6478
Practice Address - Country:US
Practice Address - Phone:865-481-2541
Practice Address - Fax:865-483-8151
Is Sole Proprietor?:No
Enumeration Date:2015-03-11
Last Update Date:2019-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN2928363AS0400X, 363A00000X
NC0010-05615363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCNCM731AMedicare PIN