Provider Demographics
NPI:1790290401
Name:RYAN, ERIC N
Entity Type:Individual
Prefix:
First Name:ERIC
Middle Name:N
Last Name:RYAN
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 1:667 AVENUE A
Mailing Address - Street 2:
Mailing Address - City:BAYONNE
Mailing Address - State:NJ
Mailing Address - Zip Code:07002-1851
Mailing Address - Country:US
Mailing Address - Phone:201-858-5923
Mailing Address - Fax:
Practice Address - Street 1:667 AVENUE A
Practice Address - Street 2:
Practice Address - City:BAYONNE
Practice Address - State:NJ
Practice Address - Zip Code:07002-1851
Practice Address - Country:US
Practice Address - Phone:201-858-5923
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-05
Last Update Date:2017-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MT000708002255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic TrainerGroup - Single Specialty