Provider Demographics
NPI:1114991700
Name:FAGAN, RYAN L (ATC LAT)
Entity Type:Individual
Prefix:MR
First Name:RYAN
Middle Name:L
Last Name:FAGAN
Suffix:
Gender:M
Credentials:ATC LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:312 E HARRISON ST
Mailing Address - Street 2:
Mailing Address - City:SWAYZEE
Mailing Address - State:IN
Mailing Address - Zip Code:46986-9570
Mailing Address - Country:US
Mailing Address - Phone:765-922-7203
Mailing Address - Fax:
Practice Address - Street 1:7756 W. DELPHI PK.
Practice Address - Street 2:- 27
Practice Address - City:CONVERSE
Practice Address - State:IN
Practice Address - Zip Code:46919
Practice Address - Country:US
Practice Address - Phone:765-384-4381
Practice Address - Fax:765-384-5414
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN36000566A2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer