Healthcare Provider Details

I. General information

NPI: 1386994986
Provider Name (Legal Business Name): RYAN EDWARDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/12/2012
Last Update Date: 09/12/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1235 E ST
FRESNO CA
93706-2024
US

IV. Provider business mailing address

1235 E ST
FRESNO CA
93706-2024
US

V. Phone/Fax

Practice location:
  • Phone: 559-268-6261
  • Fax: 559-268-7518
Mailing address:
  • Phone: 559-268-6261
  • Fax: 559-268-7518

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: