Provider Demographics
NPI:1174095590
Name:HEROLD, RYAN (FNP-C)
Entity type:Individual
Prefix:MR
First Name:RYAN
Middle Name:
Last Name:HEROLD
Suffix:
Gender:M
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4326 E SANDIA ST
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85044-3946
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2901 N CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85012-2700
Practice Address - Country:US
Practice Address - Phone:602-747-4000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-24
Last Update Date:2021-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ220211363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily