Provider Demographics
NPI:1710345996
Name:MCGOVERN, RYAN JAMES (ATC)
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:JAMES
Last Name:MCGOVERN
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 1:240 STONE MILL RD APT E101
Mailing Address - Street 2:
Mailing Address - City:LANCASTER
Mailing Address - State:PA
Mailing Address - Zip Code:17603-4624
Mailing Address - Country:US
Mailing Address - Phone:609-775-7152
Mailing Address - Fax:
Practice Address - Street 1:105 PUCILLO DRIVE
Practice Address - Street 2:
Practice Address - City:MILLERSVILLE
Practice Address - State:PA
Practice Address - Zip Code:17551
Practice Address - Country:US
Practice Address - Phone:609-775-7152
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-02-03
Last Update Date:2020-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PART0059722255A2300X
NJ25MT002198002255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer