Provider Demographics
NPI:1417355769
Name:RYAN, THOMAS GERARD (LICAC)
Entity Type:Individual
Prefix:MR
First Name:THOMAS
Middle Name:GERARD
Last Name:RYAN
Suffix:
Gender:M
Credentials:LICAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:455 BOSTON POST RD
Mailing Address - Street 2:SUITE 203A
Mailing Address - City:OLD SAYBROOK
Mailing Address - State:CT
Mailing Address - Zip Code:06475-1516
Mailing Address - Country:US
Mailing Address - Phone:860-395-1119
Mailing Address - Fax:
Practice Address - Street 1:455 BOSTON POST RD
Practice Address - Street 2:SUITE 203A
Practice Address - City:OLD SAYBROOK
Practice Address - State:CT
Practice Address - Zip Code:06475-1516
Practice Address - Country:US
Practice Address - Phone:860-395-1119
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-12-18
Last Update Date:2014-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000001171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT1013019462OtherVA