Healthcare Provider Details

I. General information

NPI: 1093769333
Provider Name (Legal Business Name): RYAN TODD DEGERSTROM PT
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 05/20/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

620 FIRE MONUMENT RD
HINCKLEY MN
55037-8304
US

IV. Provider business mailing address

2925 CHICAGO AVE
MINNEAPOLIS MN
55407-1321
US

V. Phone/Fax

Practice location:
  • Phone: 320-384-6189
  • Fax: 320-384-6181
Mailing address:
  • Phone: 612-262-4813
  • Fax: 612-262-4194

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number1675
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number6908
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: