Healthcare Provider Details

I. General information

NPI: 1639657794
Provider Name (Legal Business Name): RYAN NOVATNY MED, LAT, ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/01/2018
Last Update Date: 07/31/2026
Certification Date: 07/31/2026
Deactivation Date: 06/17/2020
Reactivation Date: 09/30/2020

III. Provider practice location address

1001 ROGERS ST
COLUMBIA MO
65216-0001
US

IV. Provider business mailing address

1001 ROGERS ST
COLUMBIA MO
65216-0001
US

V. Phone/Fax

Practice location:
  • Phone: 573-875-7407
  • Fax:
Mailing address:
  • Phone: 573-875-7407
  • Fax: 573-875-7415

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number2018019009
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: