Healthcare Provider Details

I. General information

NPI: 1689346967
Provider Name (Legal Business Name): RYAN SKOOG
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/04/2021
Last Update Date: 10/04/2021
Certification Date: 10/04/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

49725 COUNTY 83
STAPLES MN
56479-5280
US

IV. Provider business mailing address

242 W JOHNSON ST
MENAHGA MN
56464-2296
US

V. Phone/Fax

Practice location:
  • Phone: 218-894-1515
  • Fax:
Mailing address:
  • Phone: 218-849-7288
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number13765
License Number StateMN
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number13765
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: