=====================================================
General NPI Number Information
=====================================================
NPI Number | 1396968947
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JOHN BERNARD RYAN
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/11/2007
-----------------------------------------------------
Last Update Date | 09/11/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4172 PILOT KNOB RD
-----------------------------------------------------
City | EAGAN
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55122-1816
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 651-683-1006
-----------------------------------------------------
Fax | 651-890-5762
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4943 WHISPERING WAY
-----------------------------------------------------
City | EAGAN
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55122-4033
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 651-895-9352
-----------------------------------------------------
Fax | 651-890-5762
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | 2743
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | 1130953
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------