Provider Demographics
NPI:1407305717
Name:ROBERTSON, RYAN
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:
Last Name:ROBERTSON
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 1:3609 ARTESIAN AVE
Mailing Address - Street 2:
Mailing Address - City:ARMSTRONG
Mailing Address - State:IL
Mailing Address - Zip Code:61812-6811
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3609 ARTESIAN AVE
Practice Address - Street 2:
Practice Address - City:ARMSTRONG
Practice Address - State:IL
Practice Address - Zip Code:61812-6811
Practice Address - Country:US
Practice Address - Phone:217-246-4338
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-27
Last Update Date:2016-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer