Provider Demographics
NPI:1649784158
Name:CONKLIN, RYAN
Entity type:Individual
Prefix:
First Name:RYAN
Middle Name:
Last Name:CONKLIN
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 1:434 N 42ND ST APT 4
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85008-6403
Mailing Address - Country:US
Mailing Address - Phone:314-305-3039
Mailing Address - Fax:
Practice Address - Street 1:434 N 42ND ST APT 4
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85008-6403
Practice Address - Country:US
Practice Address - Phone:314-305-3039
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-11-20
Last Update Date:2017-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZHADE10490237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument SpecialistGroup - Single Specialty