Provider Demographics
NPI:1265702419
Name:KLAWON, RYAN P (AT, ATC)
Entity type:Individual
Prefix:
First Name:RYAN
Middle Name:P
Last Name:KLAWON
Suffix:
Gender:M
Credentials:AT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:CHIP FACILITY
Mailing Address - Street 2:CENTRAL MICHIGAN UNIVERSITY
Mailing Address - City:MOUNT PLEASANT
Mailing Address - State:MI
Mailing Address - Zip Code:48859-0001
Mailing Address - Country:US
Mailing Address - Phone:989-774-1663
Mailing Address - Fax:
Practice Address - Street 1:CHIP FACILITY
Practice Address - Street 2:CENTRAL MICHIGAN UNIVERSITY
Practice Address - City:MOUNT PLEASANT
Practice Address - State:MI
Practice Address - Zip Code:48859-0001
Practice Address - Country:US
Practice Address - Phone:989-774-1663
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-05
Last Update Date:2014-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI26010002842255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
020802067OtherBOARD OF CERTIFICATION (ATHLETIC TRAINER)
MI2601000284OtherATHLETIC TRAINER LICENSE