Provider Demographics
NPI:1487970133
Name:RYAN, MARK ALAN (TEACHER/REHAB)
Entity type:Individual
Prefix:MR
First Name:MARK
Middle Name:ALAN
Last Name:RYAN
Suffix:
Gender:M
Credentials:TEACHER/REHAB
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2617 SW 63RD ST
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73159-1715
Mailing Address - Country:US
Mailing Address - Phone:405-685-3530
Mailing Address - Fax:
Practice Address - Street 1:2617 SW 63RD ST
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73159-1715
Practice Address - Country:US
Practice Address - Phone:405-685-3530
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-04-19
Last Update Date:2010-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health