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General NPI Number Information
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NPI Number | 1760046767
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Entity Type | Individual
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Provider Name | RYAN MARK DOLAN LAT, ATC, OTC
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Gender | Male
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Dates
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Enumeration Date | 04/24/2019
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Last Update Date | 04/24/2019
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Provider Practice Location Address
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Address Line | 46 BARRA RD STE 103
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City | BIDDEFORD
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State | ME
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Zip | 04005-9461
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Country | US
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Telephone | 207-283-1126
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Fax | 207-294-3544
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Provider Business Mailing Address
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Address Line | 225 BEECH RIDGE RD
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City | SCARBOROUGH
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State | ME
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Zip | 04074-9105
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Country | US
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Telephone |
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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 | 246ZX2200X
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Taxonomy Name | Orthopedic Assistant
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License Number | 19-0208
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License Number State | ME
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Taxonomy #2
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Taxonomy Code | 2255A2300X
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Taxonomy Name | Athletic Trainer
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License Number | AT735
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License Number State | ME
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