Provider Demographics
NPI:1063718385
Name:ARCHIBALD, RYAN DOUGLAS (STUDENT/INTERN)
Entity type:Individual
Prefix:MR
First Name:RYAN
Middle Name:DOUGLAS
Last Name:ARCHIBALD
Suffix:
Gender:M
Credentials:STUDENT/INTERN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2615 A STREET UNIT A
Mailing Address - Street 2:
Mailing Address - City:FOREST GROVE
Mailing Address - State:OR
Mailing Address - Zip Code:97116-1411
Mailing Address - Country:US
Mailing Address - Phone:503-922-0021
Mailing Address - Fax:503-352-2261
Practice Address - Street 1:2043 COLLEGE WAY
Practice Address - Street 2:
Practice Address - City:FOREST GROVE
Practice Address - State:OR
Practice Address - Zip Code:97116-1756
Practice Address - Country:US
Practice Address - Phone:503-352-2202
Practice Address - Fax:503-352-2261
Is Sole Proprietor?:No
Enumeration Date:2011-02-03
Last Update Date:2011-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program