Healthcare Provider Details

I. General information

NPI: 1679407084
Provider Name (Legal Business Name): COLE RYAN WERKING
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/10/2026
Last Update Date: 06/10/2026
Certification Date: 06/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1025 E 7TH ST
BLOOMINGTON IN
47405-7109
US

IV. Provider business mailing address

1025 E 7TH ST
BLOOMINGTON IN
47405-7109
US

V. Phone/Fax

Practice location:
  • Phone: 812-855-1561
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: