Provider Demographics
NPI:1649720418
Name:MOREAU, RYAN
Entity type:Individual
Prefix:
First Name:RYAN
Middle Name:
Last Name:MOREAU
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 1:1090 W BETZ RD
Mailing Address - Street 2:APARTMENT 30212
Mailing Address - City:CHENEY
Mailing Address - State:WA
Mailing Address - Zip Code:99004-8400
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:207 PHYSICAL EDUCATION BUILDING
Practice Address - Street 2:EASTERN WASHINGTON UNIVERSITY ATHLETICS
Practice Address - City:CHENEY
Practice Address - State:WA
Practice Address - Zip Code:99004-2476
Practice Address - Country:US
Practice Address - Phone:906-281-4757
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-10-05
Last Update Date:2016-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
2255A2300X246Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246Z00000XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, Other
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2255A2300XOtherSPECIALIST/TECHNOLOGIST - ATHLETIC TRAINER