Provider Demographics
NPI:1316352651
Name:MAXWELL, RYAN GARDNER (NP-C)
Entity type:Individual
Prefix:MR
First Name:RYAN
Middle Name:GARDNER
Last Name:MAXWELL
Suffix:
Gender:M
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7255 SW 31ST AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97219-1806
Mailing Address - Country:US
Mailing Address - Phone:469-338-9262
Mailing Address - Fax:
Practice Address - Street 1:7255 SW 31ST AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97219-1806
Practice Address - Country:US
Practice Address - Phone:469-338-9262
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-06-25
Last Update Date:2016-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP125872363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily