Provider Demographics
NPI:1285609941
Name:VANDERVEST, RYAN EDWARD (MS, LAT, CSCS)
Entity type:Individual
Prefix:MR
First Name:RYAN
Middle Name:EDWARD
Last Name:VANDERVEST
Suffix:
Gender:M
Credentials:MS, LAT, CSCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2840 CHAR LA MAR DR
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54311-6573
Mailing Address - Country:US
Mailing Address - Phone:920-496-4750
Mailing Address - Fax:
Practice Address - Street 1:760 PILGRIM WAY
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54304-5263
Practice Address - Country:US
Practice Address - Phone:920-496-4750
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI626-0392255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer