Provider Demographics
NPI:1366419582
Name:RYAN, PEGGI (FNP)
Entity type:Individual
Prefix:
First Name:PEGGI
Middle Name:
Last Name:RYAN
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:PEGGI
Other - Middle Name:
Other - Last Name:LUCAS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:FNP
Mailing Address - Street 1:314 W 16TH ST
Mailing Address - Street 2:
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81003-2728
Mailing Address - Country:US
Mailing Address - Phone:719-546-3511
Mailing Address - Fax:719-583-1259
Practice Address - Street 1:314 W 16TH ST
Practice Address - Street 2:
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81003-2728
Practice Address - Country:US
Practice Address - Phone:719-546-3511
Practice Address - Fax:719-583-1259
Is Sole Proprietor?:No
Enumeration Date:2006-03-07
Last Update Date:2021-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1647116163WG0000X
MO107737363LF0000X
SDCP0000558363LF0000X
WY28142.1052363LF0000X
CO993030363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163WG0000XNursing Service ProvidersRegistered NurseGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO424748317Medicaid
MO424748317Medicaid
F29A128AMedicare ID - Type Unspecified