Provider Demographics
NPI:1902090020
Name:HENRY, RYAN DAVID (ATC)
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:DAVID
Last Name:HENRY
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5200 FAIRVIEW BLVD
Mailing Address - Street 2:
Mailing Address - City:WYOMING
Mailing Address - State:MN
Mailing Address - Zip Code:55092-8013
Mailing Address - Country:US
Mailing Address - Phone:651-674-2179
Mailing Address - Fax:651-674-2696
Practice Address - Street 1:6241 MAIN ST
Practice Address - Street 2:SUITE 102
Practice Address - City:NORTH BRANCH
Practice Address - State:MN
Practice Address - Zip Code:55056-6597
Practice Address - Country:US
Practice Address - Phone:651-674-2179
Practice Address - Fax:651-674-2696
Is Sole Proprietor?:No
Enumeration Date:2007-08-31
Last Update Date:2008-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN20122255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer