MEDICARE: RYAN JAMES GORMAN

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	390200000X	Student in an Organized Health Care Education/Training Program
2	2255A2300X	Athletic Trainer

General Provider Information

NPI Number	:	1437677648
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	RYAN JAMES GORMAN

Provider Business Mailing Address
First Line	:	8 MADISON CT
Second Line	:
City	:	WALLKILL
State	:	NY
Zip	:	12589-3006
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	8 MADISON CT
Second Line	:
City	:	WALLKILL
State	:	NY
Zip	:	12589-3006
Country	:	US
Telephone Number	:	845-418-9151
Fax Number	:

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

Provider Enumeration Date	:	09/07/2017
Last Update Date	:	09/07/2017

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