Healthcare Provider Details

I. General information

NPI: 1053744334
Provider Name (Legal Business Name): RYLAN MIYAT CSFA, CSA, SA-C, RSA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/09/2013
Last Update Date: 09/22/2023
Certification Date: 09/22/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1713 N CAMPBELL AVE APT G
CHICAGO IL
60647-6718
US

IV. Provider business mailing address

1713 N CAMPBELL AVE APT G
CHICAGO IL
60647-6718
US

V. Phone/Fax

Practice location:
  • Phone: 309-530-3407
  • Fax:
Mailing address:
  • Phone: 309-530-3407
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code246ZS0410X
TaxonomySurgical Technologist
License Number237000129
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number238.000499
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: