Provider Demographics
NPI:1528570751
Name:WATERS, RYAN MICHAEL (LMP)
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:MICHAEL
Last Name:WATERS
Suffix:
Gender:M
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16446 SE JONES RD
Mailing Address - Street 2:
Mailing Address - City:RENTON
Mailing Address - State:WA
Mailing Address - Zip Code:98058-8342
Mailing Address - Country:US
Mailing Address - Phone:425-635-8235
Mailing Address - Fax:
Practice Address - Street 1:1760 NEWPORT WAY NW
Practice Address - Street 2:
Practice Address - City:ISSAQUAH
Practice Address - State:WA
Practice Address - Zip Code:98027-5354
Practice Address - Country:US
Practice Address - Phone:425-998-6542
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-27
Last Update Date:2017-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA6004149225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist