Provider Demographics
NPI:1992352892
Name:RYAN, MEREDITH COOPER
Entity type:Individual
Prefix:
First Name:MEREDITH
Middle Name:COOPER
Last Name:RYAN
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:PO BOX 12
Mailing Address - Street 2:
Mailing Address - City:LIBERTY LAKE
Mailing Address - State:WA
Mailing Address - Zip Code:99019-0012
Mailing Address - Country:US
Mailing Address - Phone:406-728-3111
Mailing Address - Fax:406-728-3116
Practice Address - Street 1:601 W SPRUCE ST STE A
Practice Address - Street 2:
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59802-4047
Practice Address - Country:US
Practice Address - Phone:406-728-3111
Practice Address - Fax:406-728-3116
Is Sole Proprietor?:No
Enumeration Date:2019-08-25
Last Update Date:2023-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
MTMED-PAC-LIC-104453363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant