Provider Demographics
NPI:1447324454
Name:RYAN, LIANA GILL (PA C)
Entity type:Individual
Prefix:
First Name:LIANA
Middle Name:GILL
Last Name:RYAN
Suffix:
Gender:F
Credentials:PA C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:114 W 11TH ST
Mailing Address - Street 2:
Mailing Address - City:SILVER CITY
Mailing Address - State:NM
Mailing Address - Zip Code:88061-5136
Mailing Address - Country:US
Mailing Address - Phone:575-388-1511
Mailing Address - Fax:575-388-3465
Practice Address - Street 1:114 W 11TH ST
Practice Address - Street 2:
Practice Address - City:SILVER CITY
Practice Address - State:NM
Practice Address - Zip Code:88061-5136
Practice Address - Country:US
Practice Address - Phone:575-388-1511
Practice Address - Fax:575-388-3465
Is Sole Proprietor?:No
Enumeration Date:2006-11-20
Last Update Date:2009-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMPA2006 0037363AM0700X
NMPA2006-0037363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM14582244Medicaid
NM14582244Medicaid
Q76252Medicare UPIN