Provider Demographics
NPI:1316108012
Name:RYAN, AMELIA (MD)
Entity type:Individual
Prefix:
First Name:AMELIA
Middle Name:
Last Name:RYAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:700 NE 87TH AVE
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98664-4896
Mailing Address - Country:US
Mailing Address - Phone:360-397-3352
Mailing Address - Fax:360-604-1771
Practice Address - Street 1:501 SE 172ND AVE
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98684
Practice Address - Country:US
Practice Address - Phone:360-882-2778
Practice Address - Fax:360-604-1772
Is Sole Proprietor?:No
Enumeration Date:2008-06-24
Last Update Date:2020-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD60852601207Q00000X
IL036126424207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2106695Medicaid