Healthcare Provider Details

I. General information

NPI: 1932515285
Provider Name (Legal Business Name): RYAN FLYNN ATC, LAT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/08/2014
Last Update Date: 07/08/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2629 N 7TH ST
SHEBOYGAN WI
53083-4932
US

IV. Provider business mailing address

2075 HAZY BAY RD
TOMAHAWK WI
54487-9332
US

V. Phone/Fax

Practice location:
  • Phone: 920-451-5559
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number1494-39
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: