Provider Demographics
NPI:1063411569
Name:RYAN, KEITH G (DC)
Entity type:Individual
Prefix:DR
First Name:KEITH
Middle Name:G
Last Name:RYAN
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3319 E 46TH ST
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74135-2903
Mailing Address - Country:US
Mailing Address - Phone:918-742-6262
Mailing Address - Fax:918-742-7152
Practice Address - Street 1:3319 E 46TH ST
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74135-2903
Practice Address - Country:US
Practice Address - Phone:918-742-6262
Practice Address - Fax:918-742-7152
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-18
Last Update Date:2011-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2681111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
731533000OtherUNITEDHEALTHCARE
OK243425100Medicare PIN