Provider Demographics
NPI:1861899445
Name:WHITWORTH, RYAN
Entity type:Individual
Prefix:
First Name:RYAN
Middle Name:
Last Name:WHITWORTH
Suffix:
Gender:M
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 2077
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97208-2077
Mailing Address - Country:US
Mailing Address - Phone:503-413-3900
Mailing Address - Fax:
Practice Address - Street 1:2121 NE 139TH ST STE 205
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98686-2316
Practice Address - Country:US
Practice Address - Phone:503-413-4488
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-11-26
Last Update Date:2024-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA52172363A00000X
WAPA61553025363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant