Provider Demographics
NPI:1497101638
Name:RYAN, DREW (MS, LAT, ATC)
Entity Type:Individual
Prefix:
First Name:DREW
Middle Name:
Last Name:RYAN
Suffix:
Gender:M
Credentials:MS, LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:425 BOYLSTON ST FL 2
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02116-3324
Mailing Address - Country:US
Mailing Address - Phone:570-772-3241
Mailing Address - Fax:
Practice Address - Street 1:425 BOYLSTON ST FL 2
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02116-3324
Practice Address - Country:US
Practice Address - Phone:570-772-3241
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-05-06
Last Update Date:2024-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA30600736390200000X
MA33192255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program