Provider Demographics
NPI:1902142755
Name:DEROSE, RYAN MICHAEL (DPT)
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:MICHAEL
Last Name:DEROSE
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2500 OVERLOOK TER
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53705-2254
Mailing Address - Country:US
Mailing Address - Phone:608-280-7036
Mailing Address - Fax:608-280-7079
Practice Address - Street 1:2500 OVERLOOK TER
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53705-2254
Practice Address - Country:US
Practice Address - Phone:608-280-7036
Practice Address - Fax:608-280-7079
Is Sole Proprietor?:Yes
Enumeration Date:2012-12-26
Last Update Date:2012-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI12121-24283X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes283X00000XHospitalsRehabilitation Hospital