Healthcare Provider Details

I. General information

NPI: 1932560224
Provider Name (Legal Business Name): MICHAEL RYAN HASSETT PA-C, ATC, CSCS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/14/2016
Last Update Date: 12/03/2020
Certification Date: 12/03/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

86 THOMAS JOHNSON CT
FREDERICK MD
21702-4348
US

IV. Provider business mailing address

86 THOMAS JOHNSON CT
FREDERICK MD
21702-4348
US

V. Phone/Fax

Practice location:
  • Phone: 301-694-8311
  • Fax: 301-694-3537
Mailing address:
  • Phone: 301-694-8311
  • Fax: 301-694-3537

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberA0000742
License Number StateMD
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberC0007572
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: