Provider Demographics
NPI:1215101068
Name:NEVEAU, RYAN (PT)
Entity type:Individual
Prefix:
First Name:RYAN
Middle Name:
Last Name:NEVEAU
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 1:622 VALLEY DR
Mailing Address - Street 2:
Mailing Address - City:DULUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55804-1741
Mailing Address - Country:US
Mailing Address - Phone:218-724-3879
Mailing Address - Fax:218-728-8041
Practice Address - Street 1:622 VALLEY DR
Practice Address - Street 2:
Practice Address - City:DULUTH
Practice Address - State:MN
Practice Address - Zip Code:55804-1741
Practice Address - Country:US
Practice Address - Phone:218-724-3879
Practice Address - Fax:218-728-8041
Is Sole Proprietor?:No
Enumeration Date:2008-04-14
Last Update Date:2008-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN5900225100000X
WI10399-024225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist