Provider Demographics
NPI:1316448525
Name:DYSART, RYAN (CCP)
Entity type:Individual
Prefix:
First Name:RYAN
Middle Name:
Last Name:DYSART
Suffix:
Gender:M
Credentials:CCP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:47 PHYLIS DR
Mailing Address - Street 2:
Mailing Address - City:PLEASANT HILL
Mailing Address - State:CA
Mailing Address - Zip Code:94523-3027
Mailing Address - Country:US
Mailing Address - Phone:925-324-8406
Mailing Address - Fax:
Practice Address - Street 1:2540 EAST ST
Practice Address - Street 2:
Practice Address - City:CONCORD
Practice Address - State:CA
Practice Address - Zip Code:94520-1906
Practice Address - Country:US
Practice Address - Phone:925-682-8200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-22
Last Update Date:2018-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA3180330242T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes242T00000XTechnologists, Technicians & Other Technical Service ProvidersPerfusionist