Healthcare Provider Details

I. General information

NPI: 1033644695
Provider Name (Legal Business Name): RYAN SHANE DAMBACH
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/20/2017
Last Update Date: 03/30/2020
Certification Date: 03/30/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1073 WYOMING AVE APT 2
EXETER PA
18643-1915
US

IV. Provider business mailing address

732 OCEAN AVENUE APT 33
LONG BRANCH NJ
07740
US

V. Phone/Fax

Practice location:
  • Phone: 732-586-0326
  • Fax:
Mailing address:
  • Phone: 732-586-0326
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberRTO000324
License Number StatePA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: