Provider Demographics
NPI:1073235362
Name:RIVARD, RYAN MCCAULEY
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:MCCAULEY
Last Name:RIVARD
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 1:5995 LINCOLN DR APT 133
Mailing Address - Street 2:
Mailing Address - City:EDINA
Mailing Address - State:MN
Mailing Address - Zip Code:55436-6104
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:701 25TH AVE S
Practice Address - Street 2:
Practice Address - City:ST. PAUL
Practice Address - State:MN
Practice Address - Zip Code:55108
Practice Address - Country:US
Practice Address - Phone:612-330-1399
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-14
Last Update Date:2022-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant