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General NPI Number Information
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NPI Number | 1750798096
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Entity Type | Individual
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Provider Name | SHANE RYAN
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Gender | Male
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Dates
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Enumeration Date | 07/18/2014
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Last Update Date | 12/22/2025
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Provider Practice Location Address
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Address Line | 2817 REILLY ST
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City | FORT BRAGG
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State | NC
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Zip | 28310-2752
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Country | US
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Telephone | 734-395-3145
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Fax |
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Provider Business Mailing Address
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Address Line | 1927 FAZIO DR
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City | PINEHURST
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State | NC
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Zip | 28374-1809
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Country | US
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Telephone | 734-395-3145
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2255A2300X
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Taxonomy Name | Athletic Trainer
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License Number | LAT-5986
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License Number State | NC
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