Healthcare Provider Details

I. General information

NPI: 1588090476
Provider Name (Legal Business Name): MR. JASON ROBERT RYCKEGHEM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/24/2013
Last Update Date: 07/16/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2300 53RD AVE SUITE 100
BETTENDORF IA
52722-7564
US

IV. Provider business mailing address

2300 53RD AVE SUITE 100
BETTENDORF IA
52722-7564
US

V. Phone/Fax

Practice location:
  • Phone: 563-322-0971
  • Fax: 563-324-0615
Mailing address:
  • Phone: 563-322-0971
  • Fax: 563-324-0615

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number085.004669
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number074029
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: