Provider Demographics
NPI:1972868016
Name:WILLIS, RYAN NEAL (MAT, ATC)
Entity Type:Individual
Prefix:MR
First Name:RYAN
Middle Name:NEAL
Last Name:WILLIS
Suffix:
Gender:M
Credentials:MAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1200 MAGNOLIA WAY
Mailing Address - Street 2:PROGRESSIVE HEALTH (ESI)
Mailing Address - City:BLUE SPRINGS
Mailing Address - State:MS
Mailing Address - Zip Code:38828-6000
Mailing Address - Country:US
Mailing Address - Phone:662-317-3229
Mailing Address - Fax:
Practice Address - Street 1:1200 MAGNOLIA WAY
Practice Address - Street 2:PROGRESSIVE HEALTH (ESI)
Practice Address - City:BLUE SPRINGS
Practice Address - State:MS
Practice Address - Zip Code:38828-6000
Practice Address - Country:US
Practice Address - Phone:662-317-3229
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-07-04
Last Update Date:2012-07-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL10582255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer