Provider Demographics
NPI:1073851770
Name:ANYANWU, RYAN MICHAEL
Entity type:Individual
Prefix:
First Name:RYAN
Middle Name:MICHAEL
Last Name:ANYANWU
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5717 ALBEMARLE RD
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28212-1634
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3501 W HOLCOMBE BLVD
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77025-1313
Practice Address - Country:US
Practice Address - Phone:281-407-9341
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-01-30
Last Update Date:2024-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC2453363A00000X
NC0010-06077363A00000X
TXPA09054363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC2465PAMedicaid
NC1073851770Medicaid
NC1073851770Medicaid
NCNCR004CMedicare PIN
NCNCR004DMedicare PIN
NCNCR004AMedicare PIN
NCNCR004EMedicare PIN