Healthcare Provider Details

I. General information

NPI: 1417422635
Provider Name (Legal Business Name): RYAN GREEN PTA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/04/2018
Last Update Date: 10/04/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9108 PA-198
CONNEAUTVILLE PA
16406
US

IV. Provider business mailing address

327 ORCHID LN
SLIPPERY ROCK PA
16057-5229
US

V. Phone/Fax

Practice location:
  • Phone: 814-587-2012
  • Fax:
Mailing address:
  • Phone: 724-996-6793
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License NumberTE011793
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: