Provider Demographics
NPI:1124673074
Name:TAYLOR, RYAN MATTHEW
Entity type:Individual
Prefix:
First Name:RYAN
Middle Name:MATTHEW
Last Name:TAYLOR
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 1:13602 SUREFIRE LN UNIT 204
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40245-7787
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:13151 MAGISTERIAL DR
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40223-4103
Practice Address - Country:US
Practice Address - Phone:502-587-1236
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-07
Last Update Date:2019-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYAT15382255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer