Provider Demographics
NPI:1629705454
Name:EMMERT, RYAN
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:
Last Name:EMMERT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6 CLUB HOUSE DR STE 102
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:NJ
Mailing Address - Zip Code:07882-2213
Mailing Address - Country:US
Mailing Address - Phone:908-237-4144
Mailing Address - Fax:
Practice Address - Street 1:6 CLUB HOUSE DR STE 102
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:NJ
Practice Address - Zip Code:07882-2213
Practice Address - Country:US
Practice Address - Phone:908-237-4144
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-02
Last Update Date:2023-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NR21346100163WE0003X
NJ26NJ14916500363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163WE0003XNursing Service ProvidersRegistered NurseEmergency