MEDICARE: MR. RYAN ROBERT NELSON

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	171W00000X	Contractor		LA

General Provider Information

NPI Number	:	1205786456
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. RYAN ROBERT NELSON

Provider Business Mailing Address
First Line	:	422 W LAGRANGE ST APT 16
Second Line	:
City	:	LAKE CHARLES
State	:	LA
Zip	:	70605-1543
Country	:	US
Telephone Number	:	337-214-4305
Fax Number	:

Provider Business Practice Location Address
First Line	:	422 W LAGRANGE ST APT 16
Second Line	:
City	:	LAKE CHARLES
State	:	LA
Zip	:	70605-1543
Country	:	US
Telephone Number	:	337-214-4305
Fax Number	:

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

Provider Enumeration Date	:	01/29/2026
Last Update Date	:	01/29/2026

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Directions to “ MR. RYAN ROBERT NELSON ” Practice Location

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