Healthcare Provider Details

I. General information

NPI: 1164701876
Provider Name (Legal Business Name): RYAN MANSON C.N.P
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/11/2011
Last Update Date: 08/11/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1600 N NORTH DR
SIOUX FALLS SD
57104-0915
US

IV. Provider business mailing address

1600 N NORTH DR
SIOUX FALLS SD
57104-0915
US

V. Phone/Fax

Practice location:
  • Phone: 605-367-5068
  • Fax:
Mailing address:
  • Phone: 605-367-5068
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberCP000653
License Number StateSD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: