Individual
RYAN W ANDERSON
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
PA-C
Contact information
Practice address
3701 MACCORKLE AVE SE, CHARLESTON, WV 25304-1525
(304) 442-5151
(304) 442-7494
Mailing address
401 6TH AVE, MONTGOMERY, WV 25136-2116
(304) 442-5151
Taxonomy
Speciality
Code
Description
License number
State
363AM0700X
Medical Physician Assistant
Primary
01148
WV
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
01148
STATE LICENSE NUMBER
WV
01
—
374
WV BD. OSTEO LICENSE
WV
Enumeration date
11/03/2005
Last updated
12/13/2021
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