Provider Demographics
NPI:1023495512
Name:MASSOUD, RYAN (DO)
Entity type:Individual
Prefix:DR
First Name:RYAN
Middle Name:
Last Name:MASSOUD
Suffix:
Gender:M
Credentials:DO
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 421
Mailing Address - Street 2:
Mailing Address - City:LIBERTY LAKE
Mailing Address - State:WA
Mailing Address - Zip Code:99019-0421
Mailing Address - Country:US
Mailing Address - Phone:866-474-2455
Mailing Address - Fax:509-227-7070
Practice Address - Street 1:212 E CENTRAL AVE STE 440
Practice Address - Street 2:
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99208
Practice Address - Country:US
Practice Address - Phone:509-252-9602
Practice Address - Fax:509-227-7070
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-04
Last Update Date:2021-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOP60714919207Q00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program