Provider Demographics
NPI:1114386208
Name:FAY, RYAN
Entity type:Individual
Prefix:
First Name:RYAN
Middle Name:
Last Name:FAY
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 1:179 W 550 S
Mailing Address - Street 2:
Mailing Address - City:CUTLER
Mailing Address - State:IN
Mailing Address - Zip Code:46920-9307
Mailing Address - Country:US
Mailing Address - Phone:937-570-2448
Mailing Address - Fax:
Practice Address - Street 1:4050 BRITT FARM DR STE C
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:IN
Practice Address - Zip Code:47905-0712
Practice Address - Country:US
Practice Address - Phone:765-297-0696
Practice Address - Fax:888-377-6346
Is Sole Proprietor?:No
Enumeration Date:2016-02-17
Last Update Date:2024-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71006080A363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner