Provider Demographics
NPI:1114372752
Name:FONKERT, RYAN SCOTT (MS, ATC)
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:SCOTT
Last Name:FONKERT
Suffix:
Gender:M
Credentials:MS, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:108 ELIASEN AVE
Mailing Address - Street 2:
Mailing Address - City:WAVERLY
Mailing Address - State:IA
Mailing Address - Zip Code:50677-4415
Mailing Address - Country:US
Mailing Address - Phone:319-529-1518
Mailing Address - Fax:
Practice Address - Street 1:605 WASHINGTONE STREET
Practice Address - Street 2:
Practice Address - City:FAYETTE
Practice Address - State:IA
Practice Address - Zip Code:52142
Practice Address - Country:US
Practice Address - Phone:563-425-5664
Practice Address - Fax:563-425-5188
Is Sole Proprietor?:No
Enumeration Date:2016-05-02
Last Update Date:2018-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO5862255A2300X
IA0846782255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer