Healthcare Provider Details

I. General information

NPI: 1093262065
Provider Name (Legal Business Name): RYAN ZINKEN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/07/2016
Last Update Date: 09/07/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1900 SILVER LAKE ROAD, SUITE 110
NEW BRIGHTON MN
55112
US

IV. Provider business mailing address

217 8TH AVE S
SAUK RAPIDS MN
56379-1839
US

V. Phone/Fax

Practice location:
  • Phone: 651-746-2392
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberR 190379-5
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: