Provider Demographics
NPI:1447794573
Name:DEWOLF, RYAN MICHAEL (ATC)
Entity Type:Individual
Prefix:MR
First Name:RYAN
Middle Name:MICHAEL
Last Name:DEWOLF
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:541 SOUTH COLLEGE AVE
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:DE
Mailing Address - Zip Code:19711
Mailing Address - Country:US
Mailing Address - Phone:978-302-1857
Mailing Address - Fax:
Practice Address - Street 1:541 SOUTH COLLEGE AVE
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:DE
Practice Address - Zip Code:19711
Practice Address - Country:US
Practice Address - Phone:978-302-1857
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-12-08
Last Update Date:2016-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEJ3-00005732255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
DEJ3-0000573OtherEXAMINING BOARD OF PHYSICAL THERAPIST AND ATHLETIC TRAINERS