Healthcare Provider Details

I. General information

NPI: 1376175455
Provider Name (Legal Business Name): RYAN IVERSON PT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/06/2020
Last Update Date: 02/06/2020
Certification Date: 02/06/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

35 STATE AVE
FARIBAULT MN
55021-6368
US

IV. Provider business mailing address

2005 JEFFERSON RD APT 207
NORTHFIELD MN
55057-3196
US

V. Phone/Fax

Practice location:
  • Phone: 507-497-3790
  • Fax:
Mailing address:
  • Phone: 952-807-5466
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number11773
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: