Provider Demographics
NPI:1629300215
Name:RYAN, MITCHELL MICHAEL (LMP)
Entity Type:Individual
Prefix:MR
First Name:MITCHELL
Middle Name:MICHAEL
Last Name:RYAN
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 1:4715 S HUDSON ST
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98118-2076
Mailing Address - Country:US
Mailing Address - Phone:206-790-7645
Mailing Address - Fax:
Practice Address - Street 1:2119 17TH AVE S
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98144-4313
Practice Address - Country:US
Practice Address - Phone:206-790-7645
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-02-05
Last Update Date:2010-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60089955225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist