Provider Demographics
NPI:1669643227
Name:UPTGRAFT, RYAN WILLIAM (COTA)
Entity Type:Individual
Prefix:MR
First Name:RYAN
Middle Name:WILLIAM
Last Name:UPTGRAFT
Suffix:
Gender:M
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5939 BRIGHTON MEADOWS DR
Mailing Address - Street 2:APT. C
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46804-7664
Mailing Address - Country:US
Mailing Address - Phone:260-418-9269
Mailing Address - Fax:
Practice Address - Street 1:5939 BRIGHTON MEADOWS DR
Practice Address - Street 2:APT. C
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46804-7664
Practice Address - Country:US
Practice Address - Phone:260-418-9269
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-03-21
Last Update Date:2008-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist