Provider Demographics
NPI:1356824148
Name:KOCER, RYAN (CNP)
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:
Last Name:KOCER
Suffix:
Gender:M
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 280
Mailing Address - Street 2:
Mailing Address - City:WAGNER
Mailing Address - State:SD
Mailing Address - Zip Code:57380
Mailing Address - Country:US
Mailing Address - Phone:605-384-3418
Mailing Address - Fax:605-384-5240
Practice Address - Street 1:513 3RD ST SW
Practice Address - Street 2:
Practice Address - City:WAGNER
Practice Address - State:SD
Practice Address - Zip Code:57380-9675
Practice Address - Country:US
Practice Address - Phone:605-384-3611
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-08
Last Update Date:2018-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SDCP001437363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
SDCP001437OtherSOUTH DAKOTA BOARD OF NURSING LICENSURE