Provider Demographics
NPI:1619024544
Name:BLACK, RYAN DUANE (DO)
Entity type:Individual
Prefix:DR
First Name:RYAN
Middle Name:DUANE
Last Name:BLACK
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:201 W LAKEWAY RD STE 1004
Mailing Address - Street 2:
Mailing Address - City:GILLETTE
Mailing Address - State:WY
Mailing Address - Zip Code:82718-6349
Mailing Address - Country:US
Mailing Address - Phone:307-387-9850
Mailing Address - Fax:307-387-9890
Practice Address - Street 1:469 HIGHWAY 50
Practice Address - Street 2:
Practice Address - City:GILLETTE
Practice Address - State:WY
Practice Address - Zip Code:82718-9330
Practice Address - Country:US
Practice Address - Phone:307-387-9850
Practice Address - Fax:307-387-9890
Is Sole Proprietor?:No
Enumeration Date:2007-01-04
Last Update Date:2025-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY14427A207YX0602X, 207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
No207YX0602XAllopathic & Osteopathic PhysiciansOtolaryngologyOtolaryngic Allergy
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK208D00000XOtherTAXONOMY CODE
OK200081850AMedicaid
OK4276OtherSTATE LICENCE
OKBB9432460OtherDEA