MEDICARE: RYAN MOREAU

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	246Z00000X	Other Specialist/Technologist	2255A2300X

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	2255A2300X	OTHER	WA	SPECIALIST/TECHNOLOGIST - ATHLETIC TRAINER

General Provider Information

NPI Number	:	1649720418
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	RYAN MOREAU

Provider Business Mailing Address
First Line	:	1090 W BETZ RD
Second Line	:	APARTMENT 30212
City	:	CHENEY
State	:	WA
Zip	:	99004-8400
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	207 PHYSICAL EDUCATION BUILDING
Second Line	:	EASTERN WASHINGTON UNIVERSITY ATHLETICS
City	:	CHENEY
State	:	WA
Zip	:	99004-2476
Country	:	US
Telephone Number	:	906-281-4757
Fax Number	:

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

Provider Enumeration Date	:	10/05/2016
Last Update Date	:	10/05/2016

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Directions to “ RYAN MOREAU ” Practice Location

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