Provider Demographics
NPI:1316420326
Name:MATTISON, RYAN
Entity type:Individual
Prefix:
First Name:RYAN
Middle Name:
Last Name:MATTISON
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 1:10220 STATE HIGHWAY 31 E UNIT 3
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75705-2304
Mailing Address - Country:US
Mailing Address - Phone:817-988-5691
Mailing Address - Fax:
Practice Address - Street 1:3900 UNIVERSITY BLVD
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75799-6600
Practice Address - Country:US
Practice Address - Phone:903-565-5777
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-14
Last Update Date:2018-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program