Provider Demographics
NPI:1033644695
Name:DAMBACH, RYAN SHANE
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:SHANE
Last Name:DAMBACH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:732 OCEAN AVENUE APT 33
Mailing Address - Street 2:
Mailing Address - City:LONG BRANCH
Mailing Address - State:NJ
Mailing Address - Zip Code:07740
Mailing Address - Country:US
Mailing Address - Phone:732-586-0326
Mailing Address - Fax:
Practice Address - Street 1:1073 WYOMING AVE APT 2
Practice Address - Street 2:
Practice Address - City:EXETER
Practice Address - State:PA
Practice Address - Zip Code:18643-1915
Practice Address - Country:US
Practice Address - Phone:732-586-0326
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-20
Last Update Date:2020-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARTO0003242255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer