Provider Demographics
NPI:1295765600
Name:TANIS, RYAN N (PT)
Entity type:Individual
Prefix:MR
First Name:RYAN
Middle Name:N
Last Name:TANIS
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:18000 COVE STREET
Mailing Address - Street 2:SUITE 202
Mailing Address - City:SPRING LAKE
Mailing Address - State:MI
Mailing Address - Zip Code:49456-1383
Mailing Address - Country:US
Mailing Address - Phone:616-847-1280
Mailing Address - Fax:616-847-1290
Practice Address - Street 1:646 S. WAVERLY ROAD
Practice Address - Street 2:
Practice Address - City:HOLLAND
Practice Address - State:MI
Practice Address - Zip Code:49423
Practice Address - Country:US
Practice Address - Phone:616-994-8136
Practice Address - Fax:616-994-8162
Is Sole Proprietor?:No
Enumeration Date:2006-07-03
Last Update Date:2014-07-01
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI5501011287225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIP14760003Medicare PIN