Provider Demographics
NPI:1902462807
Name:HAVERKAMP, RYAN (PT)
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:
Last Name:HAVERKAMP
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6455 GALLERIA DR APT 5408
Mailing Address - Street 2:
Mailing Address - City:WEST DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50266-6759
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:715 W MAMIE EISENHOWER AVE
Practice Address - Street 2:
Practice Address - City:BOONE
Practice Address - State:IA
Practice Address - Zip Code:50036-3930
Practice Address - Country:US
Practice Address - Phone:515-432-5274
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-15
Last Update Date:2019-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA0921652251G0304X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2251G0304XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGeriatricsGroup - Single Specialty