=====================================================
General NPI Number Information
=====================================================
NPI Number | 1801459169
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | RYAN O'KANE DAT, LAT, ATC
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/22/2019
-----------------------------------------------------
Last Update Date | 04/22/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 418 S WARREN AVE
-----------------------------------------------------
City | MALVERN
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19355-2707
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 610-812-8248
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1224 W CHESTER PIKE APT A7
-----------------------------------------------------
City | WEST CHESTER
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19382-5664
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 610-733-3346
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2255A2300X
-----------------------------------------------------
Taxonomy Name | Athletic Trainer
-----------------------------------------------------
License Number | RT006269
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------