Provider Demographics
NPI:1720575111
Name:MAHELONA, RYAN DAVID
Entity type:Individual
Prefix:
First Name:RYAN
Middle Name:DAVID
Last Name:MAHELONA
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 1:316 S GREGG AVE
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72701-5860
Mailing Address - Country:US
Mailing Address - Phone:623-217-1716
Mailing Address - Fax:
Practice Address - Street 1:230 W CENTER ST
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:AR
Practice Address - Zip Code:72701-5934
Practice Address - Country:US
Practice Address - Phone:623-217-1716
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-20
Last Update Date:2024-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE-166832084P0800X
AZ600842084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty