Provider Demographics
NPI:1659860633
Name:PEOT, RYAN TAYLOR (ATC)
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:TAYLOR
Last Name:PEOT
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 1:2669 LONGVIEW LN
Mailing Address - Street 2:
Mailing Address - City:SUAMICO
Mailing Address - State:WI
Mailing Address - Zip Code:54173-8018
Mailing Address - Country:US
Mailing Address - Phone:920-737-9127
Mailing Address - Fax:
Practice Address - Street 1:2801 W BANCROFT ST
Practice Address - Street 2:
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43606-3390
Practice Address - Country:US
Practice Address - Phone:419-530-3542
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-06
Last Update Date:2019-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer