Provider Demographics
NPI:1033818141
Name:RYSTEDT, CONNOR RAY
Entity Type:Individual
Prefix:
First Name:CONNOR
Middle Name:RAY
Last Name:RYSTEDT
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 1:11949 WEDGEWOOD DR NW
Mailing Address - Street 2:
Mailing Address - City:COON RAPIDS
Mailing Address - State:MN
Mailing Address - Zip Code:55433-6704
Mailing Address - Country:US
Mailing Address - Phone:612-427-8082
Mailing Address - Fax:651-222-6025
Practice Address - Street 1:11949 WEDGEWOOD DR NW
Practice Address - Street 2:
Practice Address - City:COON RAPIDS
Practice Address - State:MN
Practice Address - Zip Code:55433-6704
Practice Address - Country:US
Practice Address - Phone:612-427-8082
Practice Address - Fax:651-222-6025
Is Sole Proprietor?:No
Enumeration Date:2023-02-27
Last Update Date:2023-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator