MEDICARE: RYAN ISHIHARA ATC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2255A2300X	Athletic Trainer	AT-AT-10182504	OR

General Provider Information

NPI Number	:	1205348547
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	RYAN ISHIHARA ATC

Provider Business Mailing Address
First Line	:	765 14TH ST NE
Second Line	:
City	:	SALEM
State	:	OR
Zip	:	97301-2611
Country	:	US
Telephone Number	:	503-399-3241
Fax Number	:

Provider Business Practice Location Address
First Line	:	765 14TH ST NE
Second Line	:
City	:	SALEM
State	:	OR
Zip	:	97301-2611
Country	:	US
Telephone Number	:	808-292-6907
Fax Number	:	808-292-6907

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/26/2017
Last Update Date	:	10/26/2017

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Directions to “ RYAN ISHIHARA ATC” Practice Location

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