MEDICARE: MR. RYAN EDWARD VANDERVEST MS, LAT, CSCS

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	626-039	WI

General Provider Information

NPI Number	:	1285609941
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. RYAN EDWARD VANDERVEST MS, LAT, CSCS

Provider Business Mailing Address
First Line	:	2840 CHAR LA MAR DR
Second Line	:
City	:	GREEN BAY
State	:	WI
Zip	:	54311-6573
Country	:	US
Telephone Number	:	920-496-4750
Fax Number	:

Provider Business Practice Location Address
First Line	:	760 PILGRIM WAY
Second Line	:
City	:	GREEN BAY
State	:	WI
Zip	:	54304-5263
Country	:	US
Telephone Number	:	920-496-4750
Fax Number	:

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

Provider Enumeration Date	:	02/17/2006
Last Update Date	:	07/08/2007

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