Provider Demographics
NPI:1366416869
Name:RYAN, KEITH T (MD)
Entity type:Individual
Prefix:
First Name:KEITH
Middle Name:T
Last Name:RYAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:107 E OAK AVE
Mailing Address - Street 2:SUITE 202
Mailing Address - City:FLAGSTAFF
Mailing Address - State:AZ
Mailing Address - Zip Code:86001-1818
Mailing Address - Country:US
Mailing Address - Phone:928-213-8633
Mailing Address - Fax:928-213-8634
Practice Address - Street 1:107 E OAK AVE
Practice Address - Street 2:SUITE 202
Practice Address - City:FLAGSTAFF
Practice Address - State:AZ
Practice Address - Zip Code:86001-1818
Practice Address - Country:US
Practice Address - Phone:928-213-8633
Practice Address - Fax:928-213-8634
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-14
Last Update Date:2011-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ22530207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ167339Medicaid
11WCHMN06Medicare ID - Type Unspecified
AZ167339Medicaid