=====================================================
General NPI Number Information
=====================================================
NPI Number | 1962857003
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | RYAN PINSON AT
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/26/2016
-----------------------------------------------------
Last Update Date | 04/26/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1000 E UNIVERSITY AVE DEPT. 3414
-----------------------------------------------------
City | LARAMIE
-----------------------------------------------------
State | WY
-----------------------------------------------------
Zip | 82071-2000
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 307-766-2323
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 514 E. GRAND AVE. #502
-----------------------------------------------------
City | LARAMIE
-----------------------------------------------------
State | WY
-----------------------------------------------------
Zip | 82070
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 307-760-1630
-----------------------------------------------------
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 | 073
-----------------------------------------------------
License Number State | WY
-----------------------------------------------------