Provider Demographics
NPI:1760466726
Name:MIHATA, RYAN GARNER (MD)
Entity type:Individual
Prefix:DR
First Name:RYAN
Middle Name:GARNER
Last Name:MIHATA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4700 LAS VEGAS BLVD N
Mailing Address - Street 2:
Mailing Address - City:NELLIS AFB
Mailing Address - State:NV
Mailing Address - Zip Code:89191-6600
Mailing Address - Country:US
Mailing Address - Phone:702-653-2273
Mailing Address - Fax:
Practice Address - Street 1:1 MEDICAL VILLAGE DR
Practice Address - Street 2:
Practice Address - City:EDGEWOOD
Practice Address - State:KY
Practice Address - Zip Code:41017-3403
Practice Address - Country:US
Practice Address - Phone:859-757-2927
Practice Address - Fax:859-341-0203
Is Sole Proprietor?:No
Enumeration Date:2005-12-02
Last Update Date:2024-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01066636A207P00000X
OH35.120207207RC0200X
KYC2689207RC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200964680Medicaid
IN000000625951OtherBCBS
OH35.120207OtherOH MEDICAL LIC
INM400064674Medicare PIN
INP01059123Medicare PIN
IN131180YYYMedicare PIN
INM400034670Medicare PIN
CARES000Medicare UPIN