Provider Demographics
NPI:1366997843
Name:MANSELL, RYAN (DOM)
Entity type:Individual
Prefix:
First Name:RYAN
Middle Name:
Last Name:MANSELL
Suffix:
Gender:M
Credentials:DOM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1016 E COLUMBUS DR
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33605-3333
Mailing Address - Country:US
Mailing Address - Phone:860-933-2155
Mailing Address - Fax:
Practice Address - Street 1:3965 HENDERSON BLVD
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33629-5023
Practice Address - Country:US
Practice Address - Phone:860-933-2155
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-24
Last Update Date:2016-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAP3763171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist