Provider Demographics
NPI:1093769333
Name:DEGERSTROM, RYAN TODD (PT)
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:TODD
Last Name:DEGERSTROM
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2925 CHICAGO AVE
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55407-1321
Mailing Address - Country:US
Mailing Address - Phone:612-262-4813
Mailing Address - Fax:612-262-4194
Practice Address - Street 1:620 FIRE MONUMENT RD
Practice Address - Street 2:
Practice Address - City:HINCKLEY
Practice Address - State:MN
Practice Address - Zip Code:55037-8304
Practice Address - Country:US
Practice Address - Phone:320-384-6189
Practice Address - Fax:320-384-6181
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1675225100000X
MN6908225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist