Healthcare Provider Details

I. General information

NPI: 1700399540
Provider Name (Legal Business Name): RYAN SCOTT MIZELLE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/15/2017
Last Update Date: 11/15/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6311 DEBARR RD STE J
ANCHORAGE AK
99504-1777
US

IV. Provider business mailing address

6311 DEBARR RD STE J
ANCHORAGE AK
99504-1777
US

V. Phone/Fax

Practice location:
  • Phone: 336-755-6446
  • Fax:
Mailing address:
  • Phone: 336-755-6446
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number126754
License Number StateAK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: