Provider Demographics
NPI:1396968947
Name:RYAN, JOHN BERNARD
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:BERNARD
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 1:4943 WHISPERING WAY
Mailing Address - Street 2:
Mailing Address - City:EAGAN
Mailing Address - State:MN
Mailing Address - Zip Code:55122-4033
Mailing Address - Country:US
Mailing Address - Phone:651-895-9352
Mailing Address - Fax:651-890-5762
Practice Address - Street 1:4172 PILOT KNOB RD
Practice Address - Street 2:
Practice Address - City:EAGAN
Practice Address - State:MN
Practice Address - Zip Code:55122-1816
Practice Address - Country:US
Practice Address - Phone:651-683-1006
Practice Address - Fax:651-890-5762
Is Sole Proprietor?:No
Enumeration Date:2007-04-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2743111N00000X
MN1130953183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered111N00000XChiropractic ProvidersChiropractor
Not Answered183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN64821 RYOtherBLUE CROSS BLUE SHIELD