Provider Demographics
NPI:1790645869
Name:MACON, RYAN
Entity type:Individual
Prefix:
First Name:RYAN
Middle Name:
Last Name:MACON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:863 KNOXBRIDGE RD
Mailing Address - Street 2:
Mailing Address - City:FORNEY
Mailing Address - State:TX
Mailing Address - Zip Code:75126-3858
Mailing Address - Country:US
Mailing Address - Phone:945-226-6312
Mailing Address - Fax:
Practice Address - Street 1:863 KNOXBRIDGE RD
Practice Address - Street 2:
Practice Address - City:FORNEY
Practice Address - State:TX
Practice Address - Zip Code:75126-3858
Practice Address - Country:US
Practice Address - Phone:945-226-6312
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-11-12
Last Update Date:2025-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX171M00000X, 251B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management
No171M00000XOther Service ProvidersCase Manager/Care Coordinator