MEDICARE: RYAN BLANKSON

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	103K00000X	Behavior Analyst		NV

General Provider Information

NPI Number	:	1225657083
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	RYAN BLANKSON

Provider Business Mailing Address
First Line	:	6074 SECRECT ISLAND DRIVE
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89139-0551
Country	:	US
Telephone Number	:	702-465-0657
Fax Number	:

Provider Business Practice Location Address
First Line	:	6074 SECRET ISLAND DR
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89139-6250
Country	:	US
Telephone Number	:	702-465-0657
Fax Number	:

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

Provider Enumeration Date	:	04/13/2020
Last Update Date	:	04/13/2020

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Directions to “ RYAN BLANKSON ” Practice Location

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