MEDICARE: MRS. RYAN MINOGUE

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	252Y00000X	Early Intervention Provider Agency		NY

General Provider Information

NPI Number	:	1356700249
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. RYAN MINOGUE

Provider Business Mailing Address
First Line	:	4499 HENRY HUDSON PKWY
Second Line	:	APT 8D
City	:	BRONX
State	:	NY
Zip	:	10471-3828
Country	:	US
Telephone Number	:	646-302-5802
Fax Number	:

Provider Business Practice Location Address
First Line	:	4499 HENRY HUDSON PKWY
Second Line	:	APT 8D
City	:	BRONX
State	:	NY
Zip	:	10471-3828
Country	:	US
Telephone Number	:	646-302-5802
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/19/2016
Last Update Date	:	02/19/2016

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