MEDICARE: MR. RYAN WILLIAM UPTGRAFT COTA

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	174400000X	Specialist

General Provider Information

NPI Number	:	1669643227
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. RYAN WILLIAM UPTGRAFT COTA

Provider Business Mailing Address
First Line	:	5939 BRIGHTON MEADOWS DR
Second Line	:	APT. C
City	:	FORT WAYNE
State	:	IN
Zip	:	46804-7664
Country	:	US
Telephone Number	:	260-418-9269
Fax Number	:

Provider Business Practice Location Address
First Line	:	5939 BRIGHTON MEADOWS DR
Second Line	:	APT. C
City	:	FORT WAYNE
State	:	IN
Zip	:	46804-7664
Country	:	US
Telephone Number	:	260-418-9269
Fax Number	:

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

Provider Enumeration Date	:	03/21/2008
Last Update Date	:	03/21/2008

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