Provider Demographics
NPI:1730740051
Name:AVERETT, RYAN
Entity type:Individual
Prefix:
First Name:RYAN
Middle Name:
Last Name:AVERETT
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 1:11301 JOHNSON RD
Mailing Address - Street 2:
Mailing Address - City:SOUTH PRINCE GEORGE
Mailing Address - State:VA
Mailing Address - Zip Code:23805-7100
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:11301 JOHNSON RD
Practice Address - Street 2:
Practice Address - City:SOUTH PRINCE GEORGE
Practice Address - State:VA
Practice Address - Zip Code:23805-7100
Practice Address - Country:US
Practice Address - Phone:435-327-2722
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-26
Last Update Date:2019-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer