Provider Demographics
NPI:1922636430
Name:KORN, RYAN EDWARD (MD)
Entity type:Individual
Prefix:
First Name:RYAN
Middle Name:EDWARD
Last Name:KORN
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 1:1379 W PARK WESTERN DR # 168
Mailing Address - Street 2:
Mailing Address - City:SAN PEDRO
Mailing Address - State:CA
Mailing Address - Zip Code:90732-2300
Mailing Address - Country:US
Mailing Address - Phone:732-996-7233
Mailing Address - Fax:
Practice Address - Street 1:657 N TOWN CENTER DR
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89144-6367
Practice Address - Country:US
Practice Address - Phone:702-233-7000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-30
Last Update Date:2025-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA184971207P00000X
390200000X
NV27256207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Single Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Single Specialty