Provider Demographics
NPI:1891104238
Name:SCHRADER, RYAN
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:
Last Name:SCHRADER
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 1:2416 HIGHWAY 45 N
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:MS
Mailing Address - Zip Code:39705-1320
Mailing Address - Country:US
Mailing Address - Phone:662-327-6705
Mailing Address - Fax:662-327-6760
Practice Address - Street 1:6134 U S HIGHWAY 98
Practice Address - Street 2:
Practice Address - City:HATTIESBURG
Practice Address - State:MS
Practice Address - Zip Code:39402-8530
Practice Address - Country:US
Practice Address - Phone:601-336-7155
Practice Address - Fax:601-336-7782
Is Sole Proprietor?:No
Enumeration Date:2014-08-11
Last Update Date:2014-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSATC06232255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer